Heroin injection is associated with health and social problems including hepatitis C virus (HCV) transmission. Few studies have examined the circumstances surrounding initiation to heroin injecting, especially current users initiating others. The current study aimed to examine the age of first heroin use and injection; administration route of first heroin use; relationship to initiator; the initiation of others among a group of heroin users; and to examine these factors in relation to HCV status and risk.Heroin users in Sydney were recruited through needle and syringe programs, a methadone clinic and snowballing. Participants were interviewed about their own initiation to heroin use, blood-borne virus risk and knowledge, and whether they had initiated others to heroin injecting. Information on HCV status was collected via self-report. Data was analysed using univariate and multivariate statistical techniques for Normally distributed continuous and categorical data.The study recruited 399 heroin users, with a mean age of 31 years, 63% were male, 77% reported heroin as their primary drug and 59% were HCV positive (self-report). Mean age at first heroin use and injection was 19 and 21 years, respectively. The majority of heroin users commenced heroin use via injecting (65%), younger users  were less likely than older users (>30 years) to commence heroin use parenterally. Participants were initiated to injection mainly by friends (63%). Thirty-seven percent reported initiating others to heroin injection, but few factors were related to this behaviour. Those with longer heroin using careers were more likely to report initiating others to heroin injection, but were no more likely to have done so in the preceding 12 months. Participants who had initiated others were more likely to have shared injecting equipment (12 vs 23%), but were no more likely to be HCV positive (self-report) than those who did not.Interventions to prevent heroin users initiating others to injecting are necessary. Peer groups may be well positioned to implement such interventions. Heroin is one of the most commonly injected illicit substances worldwide ,2. HeroiHepatitis C is probably the most prevalent health infection among injecting drug users (IDU) worldwide. The prevention of hepatitis C has proven difficult; unlike hepatitis B there is currently no vaccine available and programs which have been successful in reducing HIV have had only a small impact on the HCV epidemic ,14. It hA decrease in the age of initiation to drug use, including heroin use, across birth cohorts has been documented in both Australia ,18 and tet al. examined a number of factors surrounding initiation to injecting among a group of young, recently initiated IDUs [Crofts ted IDUs . They foted IDUs -23. A reted IDUs . Howeverted IDUs .et al. found that 47% of recently initiated IDUs had also initiated another into injecting and of those who had, few informed new initiates of BBVI risk [Little attention has been paid to the initiation of others into injecting . One smaBVI risk . The relCrofts and colleagues found that the majority of recently initiated IDU were aware of HIV and hepatitis B and that the viruses could be transmitted via shared injecting equipment . A much This study examined initiation to heroin injection. Specifically the study aimed to examine: 1) age of first heroin use and first heroin injection; 2) route of first heroin use; 3) relationship to initiator; and 4) the initiation of others among a group of heroin users. These factors were then examined in relation to demographic variables such as gender, ethnicity, level of education and also blood borne virus status.Heroin users in Sydney were volunteers recruited through needle and syringe programs and a methadone clinic. In order to sample a range of heroin users, snowballing, facilitated by a peer interviewer, was also used. Drug users were eligible to participate if they reported the use of heroin at least once a month in the preceding six months. All participants gave informed consent to be interviewed and received AUD20 for travel expenses.A structured questionnaire was administered to participants by trained interviewers. Information was sought on blood-borne virus status and knowledge, and initiation to heroin use and included questions on age of first heroin use, age of first heroin injection, relationship to initiator and the number of times participants had initiated others to injecting.Information on HCV status was collected via self-report. Self-reported HCV status has a concordance of approximately 80% for those who have been tested ,28. For To determine ethnicity, participants were asked how they identified ethnically, those identified as being of Aboriginal or Torres Strait Islander decent were categorised as Indigenous, those not born in Australia and those born in Australia but who identified as belonging to another ethnic group were categorised as 'other Australian'.The study was approved by four institutional ethics committees: University of New South Wales Human Research Ethics Committee, Central Sydney Area Health Service Ethics Review Committee, South Western Sydney Area Health Service Research Ethics Committee, and South Eastern Sydney Area Health Service Research Ethics Committee.t-tests and one-way analysis of variance. Linear regression was employed to test the relationship between continuous variables. The chi square (χ2) statistic was used for univariate analysis of categorical data. Multiple logistic regression, using backward elimination, was used for multivariate analysis to examine independent relationships between dichotomous variables. All data were analysed using SPSS version 11.01.Continuous variables were assessed using The sample consisted of 399 heroin users, of whom 63% were male. The mean age of participants was 31 years . The majority of participants were born in Australia (78%), a small proportion of which identified as another ethnic group. Participants were categorised as either 'Australian' (67%), Indigenous (17%) or 'other-Australian' (16%). The majority (81%) of participants had attended secondary school, but only 42 (11%) participants had tertiary education. Thirty-four (9%) participants had completed primary (elementary) school only. Sixty-one percent of participants had a history of incarceration.Heroin was the primary drug used by 77% of the sample, with a median of 9.5  years of use and injecting. The majority (98%) of the sample injected heroin; 14% of the sample had been injecting heroin for three years or less and 80% for more than three years (18 cases had missing data for this variable). Those who did not inject heroin were excluded from analysis pertaining to injecting.The mean age at first heroin use was 19 years,  and the mean age of first injection was 21 years . The mean age of first heroin use and first heroin injection was similar for males (18 years for both) and females . There were no differences in terms of ethnicity for either age of first heroin use  or first heroin injection .t395 = -1.89, p = .0.56). Participants who completed primary school only, were a mean age of 17 (SD 4.8) years when they first injected heroin and the mean age of first injection for those who attended secondary school and above was 20 (SD 6.3) years .For those who completed primary school only, the mean age of first heroin use was 17 (SD 5.4) years and 19 (SD 6.0) years for those who attended secondary school or above, the difference failed to reach significance . Similarly, current age and age of first injection were also significantly related .Heroin was most commonly first administered by injection (65%). For the 141 participants who used non-parenteral routes of administration on initiation of heroin use, the most common method was smoking (burning and chasing), with 28% of the sample reporting initiating heroin use with this method. Only seven percent first used heroin intranasally, orally or by other means.t379 = 4.36, p = 0.001).Participants who first injected heroin and those who first used heroin non-parenterally, commenced heroin use at similar ages . Those who initiated heroin use by injection had been using heroin for more years than those who initiated heroin use non-parenterally . There were no differences in the proportion of participants who commenced heroin use via injecting in terms of gender  or level of education .Route of administration was also associated with ethnicity: 74% of Indigenous participants commenced heroin use via injection, 69% of 'Australians' and 36% of 'other Australians' . Level of education was not entered into the model as there were too few participants with only primary school level of education who commenced heroin use via a non-parenteral route of administration.2 = 43.92, 4df, p < .001) and the Hosmer and Lemeshow test indicated good fit . Gender was not a characteristic independently associated with route of first heroin injection and was removed from the model. Participants aged less than 25 years and 25–30 years were less likely than those aged 30 years or more to initiate heroin use via injecting. 'Other Australians' were also less likely to reported initiating less injecting . Specifically, a greater proportion of females were taught to inject by their partner than were males , while more males were taught to inject by a friend (or other) than females . The relationship between participants and their 'initiators' did not differ according age of first injection, ethnicity or level of education across those initiated by friends, family or their partner.Participants were usually taught to inject by a friend (63%), family member (14%) or their partner (11%). Ten percent of the sample reported 'other', which was typically self-taught. Males and females differed significantly in terms of who taught them to inject (χOver a third (37%) of participants reported having taught someone to inject drugs and 17% had done so in the preceding 12 months. Among those who had ever taught someone to inject (n = 149), the median numbers of people taught was three (range: 1–200) and two (range: 1–50) in the preceding 12 months.t = -3.08, df = 370, p = 0.002). However, this difference diminished for those who had recently (preceding 12 months) taught someone to inject (11 years for both groups).Similar proportions of males and females reported teaching someone to inject ever (38% vs 37%) and in the preceding 12 months (16% vs 19%). There was also no significant difference in terms of ethnicity or mean age of those who had ever taught someone to inject ever or in the preceding 12 months. Those who had taught someone else to inject heroin had been injecting for a greater mean number of years than the remainder of the sample . Two-hundred and thirty-five participants  self-reported being HCV positive.2 = 9.14, df = 1, p = 0.003). IDUs typically become infected with HCV early in their injecting career [2 = 7.93, df = 1, p = 0.005). There was no difference in self reported HCV status between those who had initiated someone to injecting in the preceding 12 months and those who had not.Participants who reported being HCV positive initiated heroin injecting at a younger mean age  than the remainder of the sample . HCV positive participants were more likely to report initiating heroin use via injecting than those who were HCV negative . Of these, seven  reported being HIV positive. One-hundred and forty-seven participants (37%) reported having been vaccinated against hepatitis B. There were no differences between those who reported being vaccinated against hepatitis B and those who had not in terms of age at first heroin injection, initial route of administration and initiating some one else to injecting in the preceding 12 months.2 = 3.51, df = 1, p = .061).Only a small number of participants (9%) reported having used a needle or syringe after someone else in the month preceding interview. Sharing needles and syringes was not associated with mean age at initiation to heroin injection or initial route of heroin administration. More participants who had recently initiated someone to injecting (i.e. preceding 12 months) reported sharing needles and syringes (17%) than those who had not recently initiated someone (8%), though the difference failed to reach significance  and to have recently initiated someone to injecting  compared to those who not shared injection paraphernalia. There was no difference in terms of age at first heroin injection.Sharing (borrowing or lending) injection paraphrenia in the month preceding interview was reported by just over half (52%) the sample. Participants who had engaged in this behaviour were more likely to have initiated heroin use via injecting  and only 17% reported doing so in the preceding 12 months. Crofts et al. sampled only young injecting drug users (i.e. 17–24 years) [Increasing attention has been paid to the role of IDUs in initiation to injecting drug use , though 4 years) , whereasA third of the sample initially used heroin by non-parenteral routes of administration. Participants from ethnically diverse backgrounds  were more likely than other participants to have first used heroin by means other than injecting, which is consistent with other Australian research which found smoking heroin to be more common among Indochinese than Caucasian heroin users .Participants who commenced heroin use via injecting were also older than those who first used a non-injecting route of heroin administration, possibly indicating an overall shift toward non-injecting routes of administration. A number of interventions aimed at reducing the incidence of transition to injecting have received attention . One stuThe current study found a direct significant relationship between current age and age of first heroin use and first heroin injection. This result is consistent with other Australian research ,18. NeveAlthough the proportion of participants reporting using a needle or syringe after another person (sharing) in the preceding month was low, it is consistent with other research examining transitions to injecting , but lowThe majority of the sample believed themselves to be HCV positive and, not surprisingly, those who injected at a younger age were more likely to be HCV positive and to have first used heroin via injection. Though importantly, there was no difference in terms of HCV status between those who had recently taught another to inject and those who had not.This study has confirmed that initiation to heroin use in Australia typically occurs via injection, though this is less apparent among younger heroin uses. The study has also found that more than a third of heroin users have initiated others into injecting, with close to a fifth having done so recently. Many of those who engaged in this behaviour tended to take greater injection related risks which has important implications for the transmission of blood-borne infections. A better understanding of the circumstances surrounding the initiation to heroin injection is needed. Peer-led interventions, which have been found to be effective in changing IDUs' attitudes and behaviours , may havThe author(s) declare that they have no competing interests.C Day coordinated the study, was responsible for the statistical analysis and writing the paper. P Dietze was responsible for study design at the national level, secured funding and provided comments on the manuscript. J Ross and K Dolan supervised all aspects of the work and provided extensive comments on the manuscript.


HIV/AIDS is the most dramatic epidemic of the century that has claimed over two decade more than 3 million deaths. Sub Saharan Africa is heavily affected and accounts for nearly 70% of all cases. Despite awareness campaigns, prevention measures and more recently promotion of anti viral regimens, the prevalence of cases and deaths is still rising and the prevalence of systematic condom use remains low, especially in rural areas. This study identifies barriers to condom use based on the Health Belief Model (HBM) in Benin, West Africa.The study was a cross-sectional survey conducted from June to July 2002. Two hundred fifty one (251) individuals were interviewed using a structured questionnaire adapted from a standardized WHO/GAP questionnaire. A logistic regression was used to identify factors associated with condom use.In spite of satisfactory knowledge on HIV/AIDS transmission, participants are still at high risk of contracting the infection. Sixty three (63) percents of the interviewees reported being able to recognize infected people, and condom use during the last occasional intercourse was declared by only 36.8% of males and 47.5% of females. Based on the HBM, failure to use condom was related to its perceived lack of efficacy [OR = 9.76 (3.71–30.0)] and perceived quality [OR = 3.61 (1.31–9.91)].This study identifies perceived efficacy (incomplete protective effect) and perceived utilization-related problem (any reported problem using condoms) as the main barriers to condom use. Hence, preventions strategies based on increasing perceived risk, perceived severity or adequate knowledge about HIV/AIDS may not be sufficient to induce condom use. These data will be useful in designing and improving HIV/AIDS prevention outreach programs in Sub Saharan Africa. One of the current challenging tasks faced by health professionals and scientists worldwide is the prevention and control of HIV/AIDS. This disease claims yearly a huge toll of deaths, productivity and economic losses, especially in sub-Saharan Africa where the population is already weakened by poverty, malaria and tuberculosis ,2. CurtaBenin is a West-African country with a population of 6.2 million people. The male/female sex ratio is 0.96, 48.5% of the population is under age 15, the rate of literacy is nearly 30.0 % and farming as the main occupation [The sample size was calculated based on results from the Benin 2001 Demographic and Health Survey . A stratData were stored in a file using Epi info 2000  and thenThe age distribution of the study population was similar to that of the Benin population . Table 1Table The overall condom use in this population was low 34%). Table 4%. TableHowever, it is interesting to note that whilst females declared ever using condom less often than males, they declared having used the condom during the last occasional intercourse more often. In particular, even though 73% of females declared never using the condom, 47% declared having used it during the last occasional intercourse. None of these differences were significant but they clearly indicated contradictory tendencies and answers to the questionnaire. It may be that among females who ever used condom, they use it more frequently than males. Finally, the median number of sexual partners during the last 12 months varied by gender , by education (2 for some versus 1 for none) and by marital status (2 for single versus 1 for other) but not by age groups.high perceived risk of contracting HIV infection among interviewees: 94% considered themselves as vulnerable to HIV/AIDS. This proportion was higher in females compared to males. Similarly there was a high perceived severity of HIV/AIDS: 99% of females compared to 87% of males perceived HIV/AIDS as a severe and deadly disease. Conversely, there was a relatively low perceived efficacy of condom as a protective measure: only 37% of the interviewees perceived condom as an effective mean in protecting from getting HIV infection. We identified several socio-cultural barriers to behavioural change namely reported problems using condom (88% of the interviewees), the alleged capability to physically recognize an HIV infected person and the denial all together of the disease (only 19% participants believe HIV/AIDS exists). Also, cultural practices such as polygamy (20% of the study population), poverty, the belief that there is a cure for the disease (74%) and religion (9 % of non favorable reaction towards condom are among declared Christians) were all not favorable to HIV infection control.Overall, there was a Table This study was the first ever to use the Health Belief Model (HBM) to assess cultural behaviour in rural Benin towards condom use and HIV/AIDS. The HBM was reported to be one of the most widely used behavioural frameworks for more than five decades but has been criticized for its inability to efficiently predict people's behaviour . There iOur results showed there is a high awareness on AIDS in general and that women knew more about the modes of transmission of HIV/AIDS and its impacts than men. Conversely, women were more likely to feel that they could identify HIV-infected individuals from their symptoms. In addition, females were less likely to declare using condom in general even though a higher proportion declared having used condom during the last occasional sexual intercourse. This finding is disturbing and could be explained by the difference in perception of the question "do you use condoms?" It is difficult to judge what the true answer is but it is likely that rare events are better reported, and thus women may be more prone to recall the use of condom than men during occasional intercourse given that they declared on average fewer sexual partners. It is also possible that among women who do use condom, they will use it more regularly than men.Our measure of perceived vulnerability might not be sensitive enough to capture differences in perceived risks. In fact, all women and most men felt they were at risk of acquiring the infection, yet only a small proportion were using condoms. Another explanation may be that perceived risk is not a driving force in behavioural change in this subset of the population. This is an illustration of the complexity of modeling human behaviour and can thus make a case for further cultural-specific HIV-behavioural research. When only considering the percentage of condom use by gender, females appear to be at a higher risk of acquiring HIV even though they appeared to know more about transmission routes and prevention methods. This might be due to the well established difficulty facing women in negotiating the terms of sexual intercourse. In fact, gender inequality is associated with poverty, condom with distrust and sexual economic exchange is not perceived as prostitution . All theDespite a relatively acceptable knowledge of modes of transmission and prevention methods, only a few of participants declared using condoms, which is an indication that a relatively good knowledge about HIV/AIDS, even though necessary, may not be a key factor in behavioural change in fighting HIV epidemic in the study population. These findings also indicate that programmes which aim only at increasing awareness and knowledge may not succeed.Using the HBM to analyze the determinants of behavioural change in our study population, we can conclude that there is a high-perceived vulnerability and perceived severity, and yet this does not encourage condom use. An important proportion of participants do not believe in the efficacy of condoms and there are barriers to the use of condoms.Our results are comparable to that found in a similar study in the USA  and in aOne limitation of our study was that for ethical reasons, subjects less than 15 years old were excluded even though some may have already been sexually active. Also, there was a potential selection bias by not having equal number of interviewers by gender, which resulted in an over-sampling of males. Our results would be biased if the reason for poor recruitment of women was linked to their behaviours, which is not likely to be the case. There were three males interviewers for one female , and interviewer/participants must be from same gender. For the purposes of the analysis we assumed that reported knowledge and behavioural risk factors are independent. Finally there is no evidence for the validity or reliability for the original WHO questionnaire, however its use allows for comparability of results across settings.Condom use, in our study population, depends on its perceived quality and perceived efficacy. There is an indication that behavioral communication change strategies based on increasing perceived risk or vulnerability of the population or based on fear factor by increasing perceived severity of HIV/AIDS are less likely to be deterrent towards condom use and require more researches. HIV outreach programs must target more barriers of condoms use. Condom outreach programmes should be defined at community level and must be defined in association with the community, using problem-solving techniques and selecting the most relevant targets, based on their importance and changeability . Data frThe author(s) declare that they have no competing interests.SHH conceived of the study, designed the protocol, carried out and supervised the field work and data collection, performed and interpreted the statistical analysis and wrote the manuscript. HC participated in analysis and interpretation of the data, and in the writing of the manuscript. NJH contributed in earlier analysis of the data and reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


In Botswana, explicit color photos of people with AIDS have been used to spread knowledge, with the aim of saving lives Southern Africa poses special problems for AIDS educators and health care workers. Because there is a strong tradition of oral communication in the region, written educational materials often do not have as much impact as the spoken word. We have found that using colour images of HIV/AIDS in a workshop setting to provoke discussion can be a useful alternative to more conventional, written materials. In this article, we discuss our experience of using such images to raise community awareness about the AIDS epidemic in Botswana.http://www.talcuk.org/). The organisation has traditionally focused on developing countries, particularly sub-Saharan Africa and Asia. In recent years, TALC has become more global; it now distributes materials to more than 200 countries and sends educational materials on CD-ROM at no cost to health workers in developing nations.Teaching-aids At Low Cost (TALC) is a nongovernmental organisation that supplies cheap teaching aids and books to raise standards of health care and standards of living—especially in poverty-stricken areas—worldwide  and other sexually transmitted diseases, images that explained the basic virology and transmission of HIV , and imaShowing these pictures to local people was hugely controversial. For example, some elderly participants walked out when they saw the explicit pictures. Some community members approached local political counsellors to voice their concerns about a “decay of culture” and a “lack of respect”. Some parents did not want their children to see the images at all, because “they would corrupt their morals and young minds” and would encourage children to “experiment with sex”. As the team leader, I was fined chickens on several occasions by local chiefs and elders for the “crime” of showing these explicit TALC slides.The government gave our teaching project very little support in the early days; we were even cautioned by the highest authorities at the Ministry of Health. The Church, too, wanted nothing to do with our programme of “loose morals”.Despite these obstacles, over the next ten years we held over a hundred workshops, which eventually involved all government departments and levels of society in Botswana. Today, we are still using the same pictures. In 2000, the United Nations Development Programme declared Athlone Hospital's initiative as one of the “best practices” in Botswana Given the terrible impact that AIDS has had on the community, the same community members who once resisted our teaching project ask us angrily why doctors were not sufficiently aggressive in using pictures in the early days of AIDS. One telling statement made in a workshop was: “you doctors are to blame for what has happened to Africa, and particularly to our children. You should have done this ten years ago before one quarter of the population became infected. The blood of our children, who have died, rests on your heads”.info@talcuk.org .In Botswana, I used a slide projector and occasionally a mobile electrical generator, but such equipment is not widely available in most African countries. As an alternative to using colour slides, TALC has developed a folded A4 (210 mm × 279 mm) sheet with 12 colour images as a way of presenting the important messages about HIV/AIDS. This leaflet is available on request; E-mail: In our experience, the slides or leaflet work best if you can get the participants to sit in small groups for discussion. Each group should have at least one set of pictures. In your introduction, mention that to talk about sex or death is not taboo in a world of AIDS. Encourage active participation by all.Show one picture at a time—”let the picture talk”—and do not initially look at the accompanying text. Ask the participants to describe what they see in English or in the vernacular. Encourage participants to work out for themselves what the message is in the picture. Discuss all the possible answers. Then look at the text that accompanies the picture. Provide an answer built from the participants' words. If appropriate, ask people about their own relevant experiences. Finally, ask the participants to pin the pictures to the wall, making sure that each picture is put up by a different participant. Revise the lessons learned at the end of the session. Revise again, weeks later, if possible. At the end of the day, the participants should be able to say, “we did it by ourselves”.The pictures show examples of how HIV/AIDS can affect people. They must not be thought of, or used, as a way to diagnose HIV/AIDS in participants or their relatives or friends. Emphasise to all participants that if they have any reason to suspect that they (or anyone they know) have HIV/ AIDS, they should attend a clinic where trained health workers can help them.For people in Botswana, “seeing is believing”. Written descriptions are often not enough; showing pictures of herpes zoster, syphilis ulcers, or tuberculosis lymphadenopathy can be a powerful teaching tool. Once the initial shock is overcome, these colour pictures offer a straightforward way to demonstrate the realities of the disease far and wide.


Rural Indian tribes are anthropologically distinct with unique cultures, traditions and practices. Over the years, displacement and rapid acculturation of this population has led to dramatic changes in their socio-cultural and value systems. Due to a poor health infrastructure, high levels of poverty and ignorance, these communities are highly vulnerable to various health problems, especially, communicable diseases including HIV/AIDS. Our study sought to assess knowledge, attitudes and practices regarding sexuality, and the risk factors associated with the spread of HIV/AIDS and STDs among these communities.A nested cross sectional study was undertaken as part of the on going Reproductive and Child Health Survey. A total of 5,690 participants age 18–44 were recruited for this study. Data were obtained through home interviews, and focused on socio-demographics, knowledge, attitudes and behaviors regarding sexuality, HIV/AIDS and other STDs.The study revealed that only 22% of adults had even heard of AIDS, and 18 % knew how it is transmitted. In addition, only 5% knew that STDs and AIDS were related to each other. AIDS awareness among women was lower compared to men (14% vs.30 %). Regarding sexual practices, 35% of the respondents reported having had extramarital sexual encounters, with more males than females reporting extramarital affairs.Lack of awareness, permissiveness of tribal societies for premarital or extra-marital sexual relationships, and sexual mixing patterns predispose these communities to HIV/AIDS and STD infections. There is a dire need for targeted interventions in order to curtail the increasing threat of HIV and other STDs among these vulnerable populations. India is the second most populous nation in the world and has changing sociopolitical and demographic characteristics as well as varied morbidity and mortality patterns . These cAs a direct result of these challenges, India has begun to assess and monitor the impact of HIV/AIDS throughout the country's various states and regions with the assistance of several international health organizations. According to 2003 estimates from UNAIDS, approximately 5.1 million individuals in India are infected with the HIV virus . This trFor effective control of the spread of HIV/AIDS, it is crucial to have data on knowledge, attitudes and behavioral practices for specific population as research has shown that socio-cultural influences, traditional lifestyles, societal norms, and traditions influence HIV/AIDS transmission rates ,6. BecauThe rapid spread of HIV/AIDS in rural Indian communities has been attributed to the country's poor health infrastructure, poverty and lack of awareness ,10. DespThroughout India, approximately 8% of the population lives within rural tribal communities, which are collectively referred to as 'Tribes'. These communities are geographically distinct; with each tribe having its own unique customs, traditions, beliefs and practices. Even within a particular tribal entity, differences in dialect, health practices, unique customs, values, and traditions are apparent. In rural Indian communities indices of reproductive health are typically very poor: maternal mortality rate is about 230 per 100,000 live births and 61.2% of the women suffer from at least one gynecologic pathology . BecauseWe conducted a cross-sectional study nested within an existing enumerative study referred to as the Reproductive and Child Health Survey (RCHS). The RCHS was initially designed to enumerate and ascertain basic demographic and health profiles for all tribal members. Data collection for this particular study was done in two phases. Phase one involved adding additional questions to the original RCHS study to assess risk factors  associated with the transmission of HIV/AIDS and other communicable diseases.The study population comprised of tribal communities living in the southern region of Karnataka Figures ,2. MembeBecause of the enumerative nature of the RCHS, all persons within the age group 18–44 years who participated in the RCHS study were included for phase one of this study. This age group was selected as the focus of the initial study was on reproductive health issues.A semi-structured questionnaire with both open- and close-ended questions was developed to collect information on knowledge, attitudes and behaviors regarding HIV/AIDS, as well as other relevant demographic information not included in the RCHS. The instrument was developed in English, translated to the native language, and subsequently back translated to English for content and language verification. The survey instrument was field-tested for validity purposes and modified accordingly.A team of ten interviewers from the local tribal communities with a minimum of high school education were selected and trained for two weeks to ensure uniform and high-quality data collection. All adults were interviewed separately to ensure confidentiality. Each interviewer read out each of the questions and response choices (where appropriate) to the interviewees and recorded all answers directly on the questionnaire. Verbal informed consent was obtained from each respondent prior to starting the interview.Data were entered into an electronic database using Sybase Central Software . To ensure confidentiality, all respondent identifiers were expunged to create a secondary data set that was used for the final analysis. Frequency tables were generated for selected demographics and health related categorical variables. In addition, univariate analysis was performed on relevant continuous variables. The findings are presented below.Ethical clearance was obtained from ethical boards within each of the tribal communities, and appropriate government agencies were informed about the study objectives. Permission was also obtained from the Institutional Review Board (IRB) at the University of South Florida in Tampa, Florida. Verbal informed consent was obtained from the local leaders, and the individual participants. Because of the high levels of illiteracy, it was not feasible for us to obtain written consent.A total of 11,379 individuals from the 5 tribal communities had been enumerated as part of the RCHS. Of these, 5,690 were within the study age range (18–44 years) and formed the basis for this analysis.Table The findings revealed that these tribal communities did not have a structured marital system; instead members practiced a form of serial monogamy in which they change partners and remarry every four to five years. Regarding sexual practices, 35% of the respondents reported either premarital affairs or extramarital affairs Table . HoweverAmong these communities, there was a low level of knowledge on HIV/AIDS; only 22 % of all study participants  had heard of AIDS Table . Among tIn today's modern world, it is difficult to imagine societies that are still socially and culturally isolated from the rest of civilization; however, they do exist. The tribal societies throughout India have remained socially and culturally alienated from mainstream Indian society until developmental and conservation activities in tribal areas forced interactions between them. Displacement of the tribal people of southern Karnataka has led to a complex process of rapid acculturation and loss of cultural identity; as they struggle to maintain their traditional social structure, they must adopt new skills, beliefs, and practices necessary for success in their new environment. During this acculturation process, they have been faced with a myriad of public health challenges complicated by poverty, ignorance, and reluctance to abandon traditional beliefs and practices that would allow them to assimilate successfully.To date this is the first health related study among the displaced tribal communities of southern Karnataka that has attempted to assess risk threshold for the transmission and spread of HIV/AIDS and other STDs. It is not surprising that knowledge and awareness about HIV/AIDS and STDs was very low among tribal communities compared to the national figures given the degree of isolation, low literacy rates, and minimal access to information.The high level of poverty, inadequate health resources, ignorance and high-risk beliefs and practices among the tribal communities has contributed to the vulnerability of this population. As such it has created a highly susceptible population for the rapid spread of HIV/AIDS and other STDs' as well.Because tribal members are forced to migrate outside of their communities in search for work and increased wages, this may contribute to the spread of HIV/AIDS as many engage in extramarital affairs, seek commercial sex partners, or are under the threat of sexual harassment . While there has been limited scientific research exploring the cultural context of extramarital sexual behaviors, it is generally noted that in these communities, extramarital affairs are condoned and widely practiced especially during periods when women are pregnant or nursing or during period of travel for work . This kiIt is evident from this study that the Indian tribal community is experiencing a latent phase that is potentially a precursor for an HIV/AIDS epidemic. There is a high prevalence of behavioral risk factors, coupled with ignorance, and inadequate health infrastructure thus creating a potential risk for rapid spread of HIV/AIDS, as well as other related diseases. In a country that is struggling to contain the spread of HIV, it is particularly important for concerned parties to pay attention to this population. Currently, virtually no resources are allocated toward the treatment of those infected with HIV/AIDS; the main stay of management is through education and preventive measures to control the spread of the scourge as they represent the most practical and cost effective strategies in this developing nation. It therefore becomes imperative and urgent to address the health concerns revealed in our study in order to formulate effective, culture-sensitive and appropriate intervention programs so that an imminent disaster (i.e. HIV/AIDS epidemic) in this remote and isolated communities can be averted.The author(s) declare that they have no competing interests.All the authors were involved in the design of the study, analysis, interpretation and development of the manuscript.The pre-publication history for this paper can be accessed here:


The director of the United States Centers for Disease Control and Prevention gives a personal view of how the world should tackle the HIV pandemic As an intern, I took care of the first patients with HIV/AIDS at San Francisco General Hospital, and so I grew up with AIDS in the early days of my medical career. We struggled through the confusion about what was making people so sick, and each new day brought a new discovery about the disease and its consequences. I went through that evolutionary process along with everybody else, and it shaped me in many profound ways. Before long, I recognized that this wasn't a disease of “those people over there.” This was a disease that could strike anyone, anytime. And as physicians, we had to adjust our thinking about our own vulnerability to occupational risk, and to emphasize prevention, because there wasn't going to be a cure for a long, long while. And not only physicians had to rethink things—AIDS has reshaped society's very notions of the most basic human behaviors.I was in Uganda in 1985, early in the AIDS epidemic there. We knew then where that epidemic was going to go, absent an effective vaccine or cure, but few of us could have imagined that it would evolve so quickly without an end in sight. While the people of Africa have achieved a huge amount in tackling HIV/AIDS, particularly in Uganda, the epidemic is far from being under control on that continent and is spreading through other parts of the world with alarming speed.The theme of this year's International AIDS Conference in Bangkok was “Access for All.” Over the past few years, it has become increasingly apparent that a critical component of assuring access to care and treatment is human capital. Like fiscal capital, human resources are essential to ending the AIDS pandemic. I visited Africa with US Health and Human Services Secretary Tommy Thompson and many AIDS experts last December, and we saw evidence of this critical need in every country we visited. The miracles of modern science are meaningless without systems and people to deliver them to those in need.The World Health Organization estimates that of the 40 million people worldwide infected with HIV, 6 million need immediate, life-sustaining antiretroviral therapy. Fewer than 400,000 people in developing countries have access to such treatment  1,2]. T,2. T1,2]Only 360 of the 1,200 doctors trained in Zimbabwe during the 1990s continue to practice within the country.Two-thirds of University of Zimbabwe medical students intend to leave the country after graduating, and one of the country's major 1,000-bed teaching hospitals lacks a single qualified pharmacist.In Zambia, only 50 of the 600 doctors trained locally since independence have remained in the country.In Ghana, 320 nurses are recorded to have been lost in 1999, roughly equivalent to that country's annual output of nurses; losses for the year 2000 totaled 600.It has now been shown, beyond any doubt, that even in resource-poor countries with the most basic health infrastructure, people get the same benefit from treatment and prevention interventions as those in the rich world . In factWe hear the numbers—the millions upon millions infected—and we grow numb. That is why we must go to the front lines—the households and communities—and start focusing on each individual living with HIV. I was at the dedication of an AIDS clinic in Kenya. It was raining, and we were waiting outside with our umbrellas. A 12-year-old girl in front of me turned around and leaned her head against my belly and said, “Could you take me to America? I need drugs.” If you take that girl's face and multiply it a thousand times—that is the memory I bring home from Africa: the faces of the children and their asking, “Why are so many of our parents dying? Why are we dying?”We visited a US Centers for Disease Control and Prevention (CDC) program in the very remote areas of Uganda where there are no roads and it is impossible for people to come into population centers to receive HIV testing and other services. Young staff from the CDC are working with Ugandans and community organizations in that area to deliver antiretroviral therapy. Some may think that the difficulties of delivering antiretroviral therapy into such a remote area are overwhelming—and some may question whether this is a sustainable intervention. But once you see firsthand what miracles are possible, your world view changes almost overnight.What we saw was the success of a wonderful home-based treatment and care program for people who don't have access through other means. And when I say “home-based care,” picture a hut without running water or electricity, where only motorcycles are available to deliver medications. The first step of the program is to provide clean water. Coliforms and other pathogens in the water supply for the household are removed through an inexpensive water vessel fitted with a filter and through a chlorination process. In addition, a cotrimoxazole tablet is given every day, which, in one patient's words, changed his life because he began to feel well almost immediately. Not only do the cotrimoxazole prophylaxis and the water treatment improve diarrheal illness, but malarial parasitemia also drops. So that is a very positive, unexpected consequence of just two very simple and inexpensive interventions. Many patients with HIV/AIDS in Africa also have tuberculosis and are put on tuberculosis therapy in addition to cotrimoxazole. As a result, they begin to feel better even before they begin antiretroviral therapy.We spent time with one of the patients in the home-based care program. As she began to participate in these programs, tests became available to measure her CD4 count. She explained to me what her CD4 count was, what it meant, and how it improved when she started the cotrimoxazole and tuberculosis therapy. She had begun taking three antiretroviral drugs and held up her pill box to explain her regimen in detail. Every week a Ugandan health aide delivered her supply of pills on a CDC motorcycle and monitored her adherence to the treatment. Not only was she extremely reliable in taking her medications, but she also knew more about them and their side effects than most of the patients I treated at San Francisco General. She was also an expert in HIV prevention. I asked her, “What do you do to protect your three young sons from this infection?” She replied, “Every day I take them by the hand, and I go out of the house and I say, ‘Do you see that mound of dirt? That is your father’s grave. Your father acquired this fatal infection through sex. Be careful.'” And then she talks to them about the “ABCs” .So when you see a story like that unfold in the middle of Africa, it's impossible not to be hopeful. And yet, it's also very sobering because we are reminded of our responsibility. The question is not what the international health community is accomplishing in these countries now, but what we could accomplish if we joined together to really fight this war on AIDS. Such a story also inspires hope because you can see the multiplier effect that comes from taking on one problem and can see the way that effort can expand to encompass and address a much greater set of problems.When we think about successful prevention models in Uganda, “ABC” certainly stands out . HoweverThe innovative programs and ideas emerging in Africa can change the picture of the AIDS epidemic. The purchase of antiretroviral drugs for Africans is not the big challenge. Access to drugs will improve in Africa. The real challenges are delivering drugs in a safe and effective way, monitoring therapy, and sustaining the pipeline of drugs so that ongoing treatment can be guaranteed. In the example of the home-based program in Uganda, we have seen that these challenges can be overcome. Expanding access to prevention, care, and treatment services isn't going to be easy, but it is certainly possible. It will take unprecedented commitment by people in the public sector, the private sector, faith communities, and community organizations, and perhaps most importantly, individual volunteers who make up their minds to contribute in any way they can.Last fall, the US Peace Corps announced that it was activating programs in some countries that allow volunteers to help communities fight the AIDS epidemic, but this is just one of many steps that are being taken. The US president's Emergency Plan for AIDS Relief will provide $15 billion, including almost $10 billion in new funds, over five years for international AIDS assistance , and I a


Dr. Gerberding outlines critical steps for arresting the HIV/AIDS epidemic


The HIV epidemic is continuing to grow, year by year. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), in 2004 there were more people living with the virus than ever before, and in the same year more people than ever before died of it. So, although in the developed world HIV/AIDS is a controllable disease, one with which a treated person might expect to have a near normal lifespan, in much of the rest of the world AIDS is still a death sentence. Despite the fact that the cost of AIDS medicine has come down to around $150 per year in the developing world—a much lower cost than previously—the drugs are still unavailable to the vast majority of patients. What is more, every infected person has the chance of infecting many others. Although huge sums of money have been poured into combating HIV/AIDS—around US$4.7 billion in 2003—UNAIDS estimates this amount is less than half of what is required by 2005, and only a quarter of what will be required by 2007, to mount a comprehensive response to AIDS in low-income and middle-income countries. One of the real dilemmas, therefore, of HIV/AIDS policy is deciding whether it is better to concentrate resources on prevention of infections or on treatment of infected individuals. Each approach has ramifications for the other, as shown by the experience in some developed countries, where an increase in availability of treatment has been accompanied by an increase in risk behavior.PLoS Medicine suggests that trying to concentrate on one or the other of these alternatives is a false dichotomy, and that not integrating the two approaches could have a catastrophic effect on the global toll of HIV/AIDS by 2020. In this theoretical paper the authors analyze the epidemic in sub-Saharan Africa (where three-fourths of deaths from AIDS occur). With no change in current levels of prevention and care, it is predicted that there will be 3.7 million new HIV infections and 2.6 million adults dying of AIDS in this region each year within the next two decades. The authors predicted that concentrating on prevention alone could decrease yearly infections by half, and that concentrating on treatment could decrease yearly infections by 6%. However, combining both approaches could yield substantially greater benefits than the sum of the two alone—lowering projected new infections by 74% and projected annual mortality by half. These percentages translate into 29 million new infections and 10 million deaths averted between 2004 and 2020.An analysis by Joshua Salomon and colleagues in this month's The challenge now is obviously how to put these policy suggestions into practice. The current World Health Organization treatment target of having three million people on antiretroviral therapy by the end of 2005 (the “3 by 5” objective) provides a yardstick for only one part of the equation. The authors comment that the mobilization of communities that will be needed to achieve the 3 by 5 objective should also be harnessed for prevention, and that those who teach prevention must also be allowed to get care for those infected. As the authors say, only by doing so “will we at last move from slogans to impact.”


The objective was to describe the causes of initial and overall AIDS-defining disease episodes among HIV patients in Singapore.A retrospective observational cohort study was performed of all adult patients seen at the national HIV referral center between 1985 and 2001. Data were extracted from the patients' records by ten trained healthcare workers. AIDS-defining conditions were established using predefined criteria.Pneumocystis carinii pneumonia (35.7%), Mycobacterium tuberculosis (22.7%) and herpes simplex (7.4%). In total 1742 AIDS-defining episodes occurred. The most frequent causes were Pneumocystis carinii pneumonia (25.1%), Mycobacterium tuberculosis (16.2%) and cytomegalovirus retinitis (9.5%).Among 1504 patients, 834 had experienced one or more AIDS-defining diseases. The most frequent causes of the initial AIDS-defining episode were The most frequent causes of AIDS-defining illnesses in Singapore are similar to those reported in the West, prior to the introduction of anti-retroviral therapy. Opportunistic infections remain the most frequent AIDS-defining illnesses. Mycobacterium avium have decreased from 9% to 2% and 8% to 3% respectively [Pneumocystis carinii, Mycobacterium avium and other opportunistic infections have also been observed in the United States [Cohort studies have provided valuable information on the clinical course of HIV infection in patients from Europe -16, Nortectively . The proectively . Substand States ,21.Pneumocystis carinii pneumonia (7.0%) and cryptococcal meningitis (10.9%) [Relatively few data are available on the course of HIV infection in Asian populations. In Bangkok between 1987 and 1993 the most frequent AIDS-defining diagnoses were extrapulmonary tuberculosis (22.8%),  (10.9%) . Little The Communicable Diseases Centre (CDC) in Singapore is the national reference centre for adult patients with HIV and AIDS and nationwide 94.9% of all Singaporean adult residents, who have ever been diagnosed, have been referred there. Underreporting of HIV does not occur as reporting occurs automatically from the reference laboratory. Records have been kept since the first case was identified in Singapore in 1985. Therefore the Singapore HIV Observational Cohort Study (SHOCS) contains almost the entire country's HIV experience. Nucleoside analogues have been available in Singapore since the early 1990s and protease inhibitors and non-nucleoside reverse transcriptase inhibitors since 1997. The usage of these drugs has been increasing annually and during 2000 and 2001 approximately 70–80% of patients regularly attending CDC were taking some form of anti-retroviral therapy.st December 2001, by ten trained healthcare workers. Probable and confirmed criteria were developed for the diagnosis of category C [The details of the SHOCS cohort have been described previously . The stutegory C  and catetegory C .All disease episodes were initially determined by the data extractors and then checked by an infectious disease physician (RB). Diagnoses were not included if they did not fulfill the specified criteria even if there was a strong clinical suspicion of a particular condition. If there was insufficient evidence to satisfy the criteria for a specific diagnosis, a more general diagnosis was assigned, for example cerebral lesion (cause unknown) would be used if there was insufficient evidence to support a diagnosis of toxoplasmosis of the brain or primary cerebral lymphoma.Pneumocystis carinii pneumonia, Mycobacterium tuberculosis and cytomegalovirus retinitis), comparisons were made between the pre-HAART era (1986 to 1995) and the established HAART era (2000 to 2001) using χ2 tests.Median CD4 counts were calculated based on the sample taken nearest the time of diagnosis of the initial AIDS-defining condition. CD4 counts from 893 patients were used, as in 37 (4.0%) cases no suitable count was available. Data were entered into a computer database (Microsoft Access™) and checked for errors and inconsistencies. Statistical analyses were performed using Stata 7.0™. Each new or recurrent AIDS-defining condition counted as one event (i.e. a patient with three diagnoses would contribute three events). An AIDS-defining condition was counted as a separate additional event if it recurred six or more months after the initial diagnosis or in the case of tuberculosis, six or more months after treatment completion. To examine the effects of highly active anti-retroviral therapy (HAART) on the proportions of AIDS-defining illnesses due to each of the three most common infections , M. tuberculosis (22.7%), herpes simplex (chronic mucocutaneous) (7.4%) and candidiasis  (6.9%)  and Kaposi's sarcoma  than for Pneumocystis carinii pneumonia , herpes simplex  and extrapulmonary cryptococcosis  , M. tuberculosis (16.2%), cytomegalovirus retinitis (9.5%), candidiasis (7.8%), chronic mucocutaneous herpes simplex (8.2%) and disseminated M. avium (8.2%) , but that due to M. tuberculosis had increased to 18.0% . There was no significant change in the percentage of episodes due to cytomegalovirus retinitis   [Pneumocystis carinii pneumonia (4.8%) [Pneumocystis carinii pneumonia caused a much higher proportion of AIDS-defining diseases in Singapore than in Bangkok and cryptococcal meningitis occurred less frequently in Singapore.In the SHOCS cohort the proportion of conditions which were of infectious etiology remained very high throughout the study period. The distribution of conditions was similar to that seen in Western countries prior to the introduction of anti-retroviral therapy . Howevernia (7%) . Betweena (4.8%) . PneumocThe SHOCS cohort provides data on the experience of 94.9% of Singaporean residents who have been diagnosed with HIV since the epidemic began. There are good diagnostic facilities in Singapore and patients with HIV-related illness receive extensive investigations. Therefore Singapore offers an ideal location for collecting information on the causes of morbidity and mortality in persons with HIV in Asia. Medical record keeping is of a high standard in our hospital and this allowed accurate diagnoses to be assigned for AIDS-defining conditions which occurred throughout the AIDS era. To ensure consistency, data was extracted by carefully trained healthcare workers and diagnoses were assigned using predefined criteria. All AIDS-defining diagnoses and all causes of death were reviewed by the same infectious diseases physician (RB). Follow-up rates in our cohort are very high with only 5.8% of patients lost to follow-up at 12 months and 9.3% after 3 years. The SHOCS cohort therefore provides a unique source of information on HIV infection in an Asian country since the start of the epidemic.Mycobacterium tuberculosis". However if a patient receives a successful trial of treatment for disseminated M. avium, the diagnosis is "probable mycobacteriosis (species unidentified)".In a retrospective study it is impossible to ensure that all patients received a full series of investigations in order to satisfy the study criteria for diagnosis of HIV-related conditions. As a consequence the criteria for making a probable diagnosis are unavoidably biased against certain conditions. For example if a patient undergoes a therapeutic trial of tuberculosis treatment he or she can be given the diagnosis of "probable M. avium and M. tuberculosis may also have been affected by improvements in mycobacterial culture techniques.Differences in physicians' awareness of the link between HIV and opportunistic infections can influence diagnosis rates. For example, the increase in the proportion of AIDS-defining disease episodes caused by tuberculosis between 1986–1995 and 2000–2001 may have been due to greater awareness of the link between HIV and tuberculosis. Diagnosis rates for Despite the availability of anti-retroviral medication, opportunistic infections remain a common problem among HIV patients in Singapore. This may partly be explained by the high proportion of Singaporean patients, who present with advanced disease and very low CD4 counts. These patients often already have one or more AIDS-defining opportunistic infections at first presentation. Opportunistic infections may also occur before adequate immune-reconstitution can occur when HAART is commenced when the patient has a very low CD4 count. Studies in the West have shown that AIDS-defining illnesses occur more frequently among patients who have a CD4 count below 50 when anti-retroviral therapy is commenced than among those with higher CD4 counts ,38. ImmuThe current reductions in the cost of anti-retroviral therapy (Eg. due to generic manufacture) may enable high levels of anti-retroviral use to be achieved in many Asian countries. The experiences of the SHOCS cohort are likely to be repeated throughout Asia. Our results suggest that avoidable opportunistic infections may continue to occur even when high levels of anti-retroviral use are achieved. To reduce the burden of morbidity and mortality caused by these infections, efforts must be made to diagnose HIV infection earlier and to make the treatment of HIV and its associated opportunistic infections more affordable.SHOCS = Singapore HIV observational cohort study, CDC = Communicable Diseases Centre, AIDS = acquired immunodeficiency syndrome, HIV = human immunodeficiency virus, HAART = highly active anti-retroviral therapy.The authors declare that they have no competing interests.RB participated in the design of the study, supervised data extraction, performed the statistical analysis and wrote the manuscript. SS designed the database and supervised data extraction. NP participated in the design of the study and contributed to the statistical analysis and production of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


This Commentary reflects on the success of the XVI International Conference on AIDS, that was held in Toronto between August 13–18, 2006. Not only was the Conference judged to have been a scientific success, it will probably also be recognized over time as having had important political impact. It is vital that scientists and policy-makers continue to be able to interact at these meetings as part of global efforts to combat the HIV epidemic. For one week in August 2006, more than 26,000 attendees from 170 countries participated in the sixteenth biennial International AIDS Conference, held in Toronto [As repeated throughout the conference, one example of a great gap in accountability was the South African government's policy towards the HIV epidemic. Remarkably, the past three months have now witnessed a veritable revolution in South African government leadership and policy related to the AIDS epidemic. This long overdue change includes official recognition that HIV is the cause of AIDS and a commitment to provide antiretroviral drugs (ARVs) to the millions of HIV-infected South Africans who will die unless these life-saving medications are made available. This reversal in government policy comes after more than six years of official disclaimers that ARVs provided benefit and denial by President Mbeki himself that HIV was the cause of AIDS. Organizers of the International AIDS Conference, held in Durban, South Africa in 2000, will never forget the shock of realization that they and the South African government were at cross- purposes on the most important public health issue of our day.What has now prompted these welcome changes in South African policy and did the International AIDS Conference itself have a role?First, credit must go to the relentless efforts of people within South Africa, including HIV/AIDS activists, clinicians, government officials, politicians, and journalists. No-one who attended the Durban conference of 2000 will ever forget the remarks of South African Supreme Court Justice Edwin Cameron, who declared that he was gay, HIV-infected, and the fortunate recipient of ARVs. From that time to the present, coalitions of activist groups led by Zackie Achmat and Mark Heywood of the Treatment Action Campaign (TAC), and members of the South African HIV Clinicians Society have been united in attempts to bring rational decision-making in AIDS government policy to their country.In addition, it appears that the calls for accountability emanating from the International AIDS Conference in Toronto in August 2006 may also have made an important difference. The South African Minister of Health, Manto Tshabalala-Msimang, attended the Conference and remarkably stated that consumption of lemon juice, garlic, and beetroot, rather than use of ARVs, was the best way to combat the epidemic. These comments were promptly derided  as preposterous by numerous scientists and clinicians at the Conference, including ourselves. Celebrities, activists, and politicians in attendance, such as Bill Gates, Bill Clinton, Richard Gere, and Stephen Lewis all added their voice to concerns about the statements of the Minister and, more broadly, about the overall South African response,, and their comments were widely quoted in both the international and the South African press. Perhaps, this helped to develop a consensus within South Africa that Minister Manto was no longer an appropriate spokesperson on the topic of HIV/AIDS and was counterproductive to South Africa's international image and its response to the HIV epidemic. Soon after the conference, it was announced that her Deputy Minister, Nozizwe Madlala-Routledge, would now assume responsibility for the HIV/AIDS portfolio. Furthermore, Deputy-President Phumzile Mlambo-Ngcuka, rather than President Mbeki himself, would now be in charge of overall government policy on AIDS.  These changes suggest that pressures within the African National Congress, the governing party of South Africa, must finally have become so intense as to force this turnaround. Doubtless, the timing is also related to multiple political and other factors that impacted on these decisions.We may never know the reasons that Mbeki, one of the most respected African leaders, was captured by HIV denialism. What is clear, however, is that the confusion sown by his denials of HIV as the cause of AIDS may have resulted in the needless, additional infections of hundreds of thousands of his co-citizens.It is impossible to know the role that the 2006 International AIDS Conference played in influencing South Africa's AIDS policy. However, the many voices, including those of internationally recognized figures, must surely have played some part in making patently obvious the increasingly negative impact that these policies were having on South Africa's image and on the lives of people with HIV in South Africa.This is but one example of the powerful role these conferences have played over the years in shaping policy. The stories that journalists wrote and broadcast from the Conference raised HIV/AIDS awareness throughout the world, and probably did more to prevent new cases of HIV transmission than any single scientific presentation at the Conference, although, to be sure, the Conference included a large number of novel reports that point the way to improvements in the prevention and treatment of HIV disease.This and the fact that the International AIDS Conference seems to have played a role in catalyzing government change in South Africa on the topic of AIDS is one example of the importance of continuing to organize this event on a semi-annual basis. The International AIDS Conference attracts more media attention than any medical conference in the world, and the AIDS community must take advantage of this for as long as HIV/AIDS remains the world's most important public health problem. We are grateful to have had the opportunity to work together with our colleagues at the International AIDS Society, at several international non-governmental organizations, and with member of the Toronto Local Host community toward the success of this major event.The author(s) declare that they have no competing interests.


There has been dramatic improvement in survival for patients with HIV/AIDS; however, some studies on patients with HIV/AIDS and serious illness have reported continued low rates of intensive care. The purpose of this study was to examine patterns of care and outcomes for patients with severe sepsis and HIV/AIDS and compare them with those of patients with severe sepsis without HIV/AIDS.We assessed data from all 1999 discharge abstracts from all non-federal hospitals in six US states. Patient demographic characteristics, discharge diagnoses, resource use, and outcomes were extracted. Analyses were performed using chi-square, Wilcoxon rank sum, or regression techniques, as appropriate.We identified 74,020 patients with severe sepsis  had HIV/AIDS) using ICD-9-CM codes. Patients with severe sepsis and HIV/AIDS had a similar mean length of stay , had lower mean hospitalization cost , were less likely to be admitted to the intensive care unit , and had a greater mortality  than those without HIV/AIDS. After adjustment for cohort differences, patients with severe sepsis and HIV/AIDS had increased likelihood of death (OR (95% CI) = 2.41 (2.23–2.61)) and were substantially less likely to be admitted to the intensive care unit (OR (95% CI) = 0.54 (0.51–0.59)). When compared with those with severe sepsis and HIV/AIDS, patients with severe sepsis without HIV/AIDS were universally more likely to be admitted to the intensive care unit, even when they had comorbid illnesses with equal or worse expected in-hospital mortality .For patients with severe sepsis, there are differences in care and outcomes for those with HIV/AIDS. Further research is needed to examine the delivery of care for patients with severe sepsis and HIV/AIDS. With the advent of highly active antiretroviral therapy (HAART) in the late 1990s, opportunistic infection and mortality rates for patients with HIV/AIDS have dramatically decreased, thus transforming HIV/AIDS from a uniformly fatal condition to a more manageable chronic illness . ImproveIn 1992, the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference arrived at the current definition of severe sepsis (SS) as a systemic inflammatory syndrome in response to infection that is associated with acute organ dysfunction . SubsequData from discharge abstracts for calendar year 1999 from all non-federal hospitals from six US states  were assessed. We selected those states based on geographic representation, data quality and availability. Data extracted included: patient demographic characteristics; diagnoses and procedures  classified by the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes; resource use , ICU use, total charges); and in-hospital mortality.Because no ICD-9-CM code existed at the time these data were collected that directly identified cases of severe sepsis, we identified cases by using an algorithm described by Angus and colleagues  and adapWe defined a case as surgical if there was an ICD-9-CM code for an operating room procedure other than tracheostomy. Teaching hospital status was determined from the Health Care Financing Administration Provider Specific File . Using cReported outcomes were ICU use , hospital length of stay, total cost of the admission, and in-hospital mortality. We estimated the cost for each case by multiplying total charges by the sum of the hospital-specific Medicare capital and operating cost-to-charge ratios .t test to compare continuous data. Odds ratios (ORs) were determined using simple regression. Adjusted analyses were performed using multivariable logistic or linear regression, as appropriate. All available covariates were included in the multivariable models. So that the results would be easily interpretable, interactions among variables were not pursued. The adjusted R2 or c-statistic is presented for each of the models. Although distributions for LOS and cost were not normally distributed, results were qualitatively similar whether analyses were performed with those values log transformed or not. Thus, we chose to not transform the data to facilitate interpretation.The databases were constructed in Foxpro  and analyses were conducted using SAS version 8.2 . We used chi-square or Fisher's exact test to compare categorical characteristics and Student's To assess the robustness of our results, we performed additional stratified analyses. Specifically, additional analyses evaluating mortality and ICU admission were stratified by HIV/AIDS disease severity (presence of opportunistic infection or not) and additional outcomes comparisons were performed specifically with metastatic cancer  diagnoses. Also, because of the imbalance in characteristics between those with and without HIV, we were concerned about the robustness of our multivariable results. Thus, we performed additional analyses in subgroups with 'matched' characteristics. Specifically, we performed two additional analyses where we limited the cohort to patients aged 41 to 60 years without comorbidities (other than HIV for those with HIV infection) covered by Medicaid or Medicare who were admitted to a medical service in a teaching hospital. In the first analysis, we assessed only those admitted with respiratory infections but without opportunistic infections and compared outcomes for those with and without HIV infection. In the second analysis, we limited the analysis to only those admitted with opportunistic infections and compared outcomes for those with and without HIV.We identified 74,020 cases of severe sepsis, 10.3%  with HIV/AIDS  compared with those without HIV/AIDS  despite a statistically significant greater overall mortality , patients with SS and no cormorbidities (OR (95% CI) = 0.36 (0.33–0.39)), or only diabetes (OR (95% CI) = 0.37 (0.33–0.42)), pulmonary disease (OR (95% CI) = 0.38 (0.33–0.43)), cardiovascular disease (OR (95% CI) = 0.39 (0.33–0.47)), or renal disease (OR (95% CI) = 0.67 (0.56–0.80)) were significantly less likely to die , covered by Medicaid or Medicare, who were admitted to a medical service in a teaching hospital, we obtained similar results to the results from the whole cohort whether we assessed patients who had respiratory infections (without opportunistic infections) or whether we looked only at those with opportunistic infections. In the 'matched' cohort with respiratory infections, those with HIV had, on average, significantly less costly hospital stays ; had shorter hospital stays ; were more likely to die (OR (95% CI) = 1.86 (1.35–2.56)); and were less likely to be admitted to the ICU (OR (95% CI) = 0.47 (0.35–0.63)). When we focused only on those with opportunistic infections, those with HIV had, on average, significantly less costly hospital stays ; had shorter LOS ; and were less likely to be admitted to the ICU (OR (95% CI) = 0.38 (0.25–0.59)) despite similar likelihood of death (OR (95% CI) = 1.31 (0.82–2.08)).In this HAART-era study, we found that patients with SS and HIV/AIDS overall had less costly hospitalizations, were less likely to be admitted to the ICU, and had a greater in-hospital mortality than those without HIV/AIDS. HIV/AIDS patients had similar LOS, lower hospitalization costs, and greater mortality than those without HIV/AIDS whether they lived, died, or were admitted to the ICU. However, for patients with SS not in the ICU, the trends were different. Specifically, those with HIV/AIDS had significantly longer LOS and had somewhat higher mean hospitalization costs  than those without HIV/AIDS. We also found that when compared with those with SS and HIV/AIDS, patients with SS without HIV/AIDS were universally more likely to be admitted to the ICU, even when they had comorbid illnesses with equal or worse expected in-hospital mortality . Those results were robust with qualitatively similar results in univariate, multivariable, and subgroup analyses.Pneumocystis carinii pneumonia with and without HIV/AIDS and had similar findings. What is unclear and cannot be discerned from our data is whether that difference in care is inappropriate because of physician or healthcare system bias or whether the difference is appropriate and based on differences in patient preference  or clinical differences between patients with and without HIV/AIDS. Existing evidence suggests there may be clinical biases against aggressive treatment of patients with SS and HIV/AIDS [Despite having higher mortality rates, patients with SS and HIV/AIDS were significantly less likely to be admitted to the ICU than patients with SS without HIV/AIDS. Nicolau and colleagues  studied HIV/AIDS -26. In oHIV/AIDS -26 specuvis-à-vis aggressive care and, thus, may have had their care decelerated, decreasing the use of aggressive measures and increasing use of palliative measures like hospice. Nonetheless, physicians caring for in-patients with HIV/AIDS, as well as the patients themselves, should be made aware of improvements in outcomes for critically ill patients with HIV/AIDS before making decisions about withholding or withdrawing aggressive care [The explanation for differences in ICU use may also lie in patient preferences. Given the emphasis on advanced directives in patients with HIV/AIDS that began before the HAART era -34, it iive care -9.Pneumocystis carinii pneumonia [In regards to our cost results, we suspected that the cost differences might be explained by the differences in ICU admission and mortality ; however, the difference in cost persisted even after stratifying by mortality, and in fact, for those not admitted to the ICU, costs were similar for those with and without HIV/AIDS. Furthermore, the difference in cost persisted even in our adjusted analyses that accounted for additional issues such as LOS, comorbidities, and failing organ systems, as well as in our 'matched' subgroup analyses. Others have compared resource use between patients with and without HIV/AIDS -37. In tneumonia . The resThe major limitations of our study relate to the use of administrative data. The general issues with using administrative data for research have been well documented by others ,39. SpecDespite the limitations, our study has several notable strengths. First, our finding of less aggressive care  were robust with consistent findings using different analysis assumptions and methodologies. Second, using a large, multi-state administrative database allows us to easily generate reliable estimates of outcomes obviating the need for a large multi-center study and permits examination of care patterns and resource use simultaneously. Furthermore, our study has more power and generalizability than the small, single-site studies that have provided much of the evidence base for care of critically ill patients with HIV/AIDS ,8,40-44.In conclusion, we found a difference in care and outcome for patients with SS and HIV/AIDS, in that they had less costly hospitalizations, were less likely to be admitted to the ICU, and had greater in-hospital mortality than those without HIV/AIDS. Further research is needed to examine whether that difference in care persists over time and if it is inappropriate because of physician or healthcare system bias or whether the difference is appropriate and based on differences in patient preference or clinical differences between patients with and without HIV/AIDS.• 	We found that patients with SS and HIV/AIDS overall had less costly hospitalizations, were less likely to be admitted to the ICU, and had a greater in-hospital mortality than those without HIV/AIDS.• 	HIV/AIDS patients had similar LOS, lower hospitalization costs, and greater mortality than those without HIV/AIDS whether they lived, died, or were admitted to the ICU.• 	When compared with those with SS and HIV/AIDS, patients with SS without HIV/AIDS were universally more likely to be admitted to the ICU, even when they had comorbid illnesses with equal or worse expected in-hospital mortality .• 	Further research is needed to examine whether that difference in care persists over time and if it is inappropriate because of physician or healthcare system bias or whether the difference is appropriate and based on differences in patient preference or clinical differences between patients with and without HIV/AIDS.CI = confidence interval; HAART = highly active antiretroviral therapy; ICD-9-CM = International Classification of Diseases, 9th revision, Clinical Modification; ICU = intensive care unit; LOS = length of stay; OR = odds ratio; SS = severe sepsis.JAJ and LB are full-time employees of Eli Lilly and Company. JMM and WTL have received research funding from Eli Lilly and Company. JMM is currently employed at GlaxoSmithKline.JMM designed the study, performed the analyses, and drafted the manuscript. LB conceived the project, assisted with interpretation of the data, and critically reviewed and revised the manuscript for important intellectual content. MSY assisted with analysis and interpretation of the data, and critically reviewed and revised the manuscript for important intellectual content. WTL acquired the dataset, assisted with analyses, and critically reviewed and revised the manuscript for important intellectual content. JAJ assisted with interpretation of the data, and critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final manuscript.


Failure to halt and reverse the HIV/AIDS epidemic, say the authors, will continue to jeopardize progress on achieving a wide range of the MDGs. But in other regions, most notably in sub-Saharan Africa, a large number of countries are far behind and appear unlikely to reach, or even come close to reaching, their goals for 2015 [The reasons for this are complex and often interlinked, but one stands out as a major overarching threat to development: HIV/AIDS, which kills more people than any other infectious disease and is the fourth-leading cause of death worldwide . The sevThis Policy Forum reviews the literature on the impact of AIDS on selected MDGs, and explores the links between fighting AIDS and improving other development outcomes. It also considers the implications for developing country and donor investment strategies, arguing that expanded investment in HIV prevention—especially in new prevention tools including AIDS vaccines—is essential for attaining and upholding the MDGs.We examine how HIV/AIDS impedes progress toward several of the MDGs, beyond the direct target dedicated to reducing the HIV epidemic itself. Based on availability of data, we focus on the following MDGs: (1) eradicating extreme poverty and hunger; (2) achieving universal primary education; (3) reducing child mortality; (4) improving maternal health; and (5) combating malaria and tuberculosis (TB).Our analysis draws on primary sources published over the past five years (2000–2005). The literature search, conducted between January and November 2005, relied on general searches of the PubMed database, in addition to consultations with experts from the respective fields to identify key representative peer-reviewed articles.We give a snapshot of the effects of HIV/AIDS on each of the MDGs. The approach does not attempt to capture all the interactions among these development outcome measures. In addition, the paper is unidirectional in its analysis of the impact of AIDS: it does not try to explain, for instance, how poverty may increase transmission of and susceptibility to HIV. These relationships have been explored elsewhere .Various studies, using a range of modeling techniques, argue that AIDS lowers national gross domestic product (GDP) growth by up to 1.5% annually . An analHouseholds face revenue losses and heavy costs. Because of high medical costs, as well as other expenses, of HIV-related illness and death, and because AIDS often kills working-age adults, the epidemic has a significant impact at the household level. Studies from Thailand and South Africa show that poverty is higher among households affected by HIV and AIDS than among unaffected families ,13.A recent analysis of household data from Botswana, drawing on income and expenditure surveys, suggests that HIV/AIDS can be expected to lower average income per capita by 10% over the next ten years. It also shows that the income loss is twice as large among the poorest households as it is for the overall population, suggesting that extreme poverty will become entrenched because of HIV/AIDS . A similThese effects will escalate over time. The long-term negative impact of AIDS can be expected to accelerate. Classic GDP growth models may fail to capture the negative long-term intergenerational effects of HIV/AIDS.One analysis that models the impact of HIV/AIDS over three generations shows how AIDS could produce a progressive collapse of the economy. Declining family income forces parents to choose immediate consumption  over long-term investments in the next generation's human capital . As a result, children of parents who die of AIDS have less human capital to pass on to their own children .The steadily increasing number of orphans in developing countries indicates how severe this problem could become . In SoutWorldwide, 53% of annual deaths among children under five are associated with malnutrition .Some data suggest that HIV/AIDS contributes to food crises in areas where HIV prevalence is high . For exaAIDS also affects child nutrition through parental mortality. Orphaned children are less likely to receive adequate nutrition. For example, in the Kagera region of Tanzania, maternal orphans lost on average one standard deviation in height, while paternal orphans' height declined one-third of a standard deviation . A studyThe AIDS epidemic can negatively affect both the demand for and supply of education. AIDS may prevent children from enrolling in school, or cause them to be taken out of school. It can also cause absenteeism and mortality of teachers and staff, lowering educational quality and preventing children from obtaining schooling.AIDS reduces the demand for schooling. Children in areas affected by AIDS may drop out of school because they or their families cannot afford fees or supplies, or because their families increasingly rely on them to contribute economically to the household or to care for ill family members. In a study in the Kagera region of Tanzania, young children (seven to ten years of age) who lost their mothers had their schooling delayed, though enrollment of older children (11–14 years of age) was not affected . A surveAnother study, however, suggests that orphan status may not have a significant bearing on school enrollment . The surThe theory that orphans experience disadvantages when they are not closely related to the head of the household could explain the discrepancy in these results. A review of 19 Demographic and Health Survey studies in ten African countries found a correlation between enrollment of orphans and the degree to which they were related to their guardians .AIDS also hampers countries' abilities to supply education. In many countries, educational administrators face substantial challenges in replacing teachers who die. Even when replacement teachers are readily available, the death of a teacher imposes substantial costs  on education systems .A comprehensive study of public schools in South Africa provides an overview of the attrition of educators and of mortality trends . Data frWorldwide, approximately 10.6 million children under five died in 2003. More than 40% of these deaths occurred in Africa . Many coThough AIDS contributes only modestly to global child mortality ,30, the AIDS increases child mortality directly and indirectly. The vast majority of children living with HIV acquired the virus through perinatal transmission. And 60% of children with HIV die before their fifth birthday . In thisChild mortality can be attributed to AIDS even when HIV is not the direct cause of death, since children are made vulnerable to a range of economic and social “injuries” caused by their parents' illness and death. Maternal HIV status is a strong predictor of child survival, regardless of a child's HIV status . SeveralWhen the analysis breaks down HIV-related proportional attributable child mortality for individual countries for 1999, countries with high prevalence show the effect of HIV even more strongly . For insEach year, more than 500,000 women die from pregnancy and childbirth-related complications, and at least 10 million suffer serious injuries or disabilities. More than 80% of these deaths occur in sub-Saharan Africa and South Asia .HIV/AIDS can significantly increase maternal mortality ratios. Evidence suggests that suppressed immunity causes higher risks of prenatal and childbirth complications including miscarriage, anemia, postpartum hemorrhage, and puerperal sepsis, in addition to increasing the chances of dying from indirect causes during and after pregnancy, such as malaria or pneumonia .Thus, maternal mortality ratios for women who are HIV positive can be substantially higher than for those who do not have HIV. For example, in Malawi and Zimbabwe, surveys suggest that the risk of pregnancy-related death is eight to nine times higher in women who are HIV positive. When HIV prevalence rates among pregnant women increased 10-fold between 1991 and 2001 in these countries, overall maternal mortality increased 1.9 and 2.5 times, respectively, likely as a result of this heightened risk . A similA study in South Africa shows that the proportion of maternal deaths due to indirect infections (including HIV) increased from 23% to 31% over the period 1998–2001, making these infections the most significant causes of maternal mortality . In highRecent studies suggest that HIV has significant effects on the incidence of malaria. HIV-induced immunodeficiency may decrease the immune response against malarial infection , and indHIV co-infection in areas where malaria transmission is intense primarily increases the risk of parasitemia and clinical malaria in adults , and cliClinical studies have also shown that HIV affects the incidence of malaria and disease progression in pregnant women. Increased rates of peripheral and placental parasitemia, higher parasite densities, and higher incidence of malaria, anemia, febrile illnesses, and adverse birth outcomes have been documented with HIV and malaria co-infection .Infection with HIV also affects the treatment and prophylaxis of malaria. Antimalarial therapy works best in individuals with some previous immunity to malaria, so the immune suppression associated with HIV infection may decrease the response to antimalarial therapy .The epidemics of HIV and TB are closely intertwined. Of the 40 million individuals who are HIV positive worldwide, it is estimated that nearly one-third are also infected with TB . BecauseThe risk of acquiring TB doubles soon after HIV infection, and increases during subsequent years ,50. One Thus TB rates are actually increasing in high-HIV-prevalence areas of sub-Saharan Africa , and theThere has been considerable progress on the global response to AIDS, with a concomitant increase in resources for the currently available range of interventions. Yet AIDS continues to ravage large parts of the world today: nearly 40 million people were living with the disease as of the end of year 2005, and more than 4 million were newly infected last year .Failure to halt and reverse the AIDS epidemic will continue to jeopardize progress toward achieving a wide range of the MDGs. It will not only thwart the direct objective—stopping HIV infection and AIDS-related illness itself—but it will also undermine progress in areas as diverse as lowering poverty rates, ensuring that all children complete primary education, reducing child death rates, improving maternal health, and fighting the global malaria and TB epidemics.From now until the 2015 MDG target date, it is essential that the delivery of existing interventions for prevention, treatment, and mitigation of the social effects of HIV be dramatically increased. The recent release of a prevention strategy from the Joint United Nations Programme on HIV/AIDS—which advocates increased funding, intersectoral efforts, and strengthening of institutional capacity—is a welcome development .Yet more must be done to link HIV prevention to other development programs to ensure that they adequately address the effects of AIDS that extend beyond the domain of health to reduce the pandemic's negative effects on progress toward other social and economic goals. HIV/AIDS programs should be at the center of overall development strategies.At the same time, it is essential to invest in the development of the new and better technologies needed for more-effective prevention, diagnosis, and treatment of HIV/AIDS. In addition to expanding treatment programs to prolong the lives of those living with HIV, the best chance of ultimately controlling the epidemic will come from new preventive technologies—notably vaccines and microbicides. Models of the impact of even partially effective vaccines with modest uptake estimate that 30–70 million individuals could be protected from HIV over 15 years of use .Part of the commitment to long-term prosperity for the world's poorest countries must therefore include investing in these HIV prevention tools for the future. Governments, donors, and civil society need to increase funds for HIV prevention research and product development, and build political support, especially for the deeper involvement of developing countries. The international community must also promote expanded industry participation, a more-coordinated scientific effort, and policies and programs that accelerate the testing of novel vaccines and microbicides. Such actions are needed today and must be maintained in the future, including after 2015. The MDG targets can help assess progress and motivate political support, yet the goal of global development should be not just for 2015 but also for the entire 21st century.