Government responses to HIV/AIDS in Africa: what have we learnt?

While we should not lose sight of the development of vaccines and cures, more immediate priorities include the implementation of effective STD control. The syndromic management approach developed in Zimbabwe to overcome laboratory constraints is a cost-effective way of managing STD. Of urgency is the integration of STD services into primary health-care services, appropriate training of staff, adequate provision and control over drugs and condoms, and incorporation of traditional healers and community-based education on STD. A second area of priority is the strengthening of the interaction between prevention, care and support activities, which act in synergy. Effective prevention and care require easy access to testing facilities with pre- and post-test counselling, appropriate structures and services to provide affordable and sustained care and support to those found to be infected with HIV, provision of drugs for the treatment of opportunistic infections, and the creation of a social environment and a legislation which protect against any form of discrimination the rights of people living with HIV, their sexual partners and their families.

Mortality impact of AIDS in Abidjan, 1986-1992.

OBJECTIVES: To quantify the mortality impact of AIDS in the city of Abidjan (Côte d'Ivoire) by a full scale analysis of mortality trends before and after the onset of the epidemic. DESIGN: Data on deaths registered in the 10 vital registration centers of the city between 1973 and 1992, and data on causes of deaths in the four public hospitals were coded and investigated. Data on deaths were compared with census data in order to compute death rates. METHODS: Life tables were computed for each of the 20 years of the study. The trends in death rates were analysed during the 10 years before the onset of the AIDS epidemic (1973-1982) and compared with the changing death rates in the following 10 years (1983-1992). Deaths attributable to AIDS were defined as those in excess of the original trends. The evolution in the number of deaths in the hospital allowed an analysis by cause of death. RESULTS: There was a marked increase in death rates starting in 1986, date of the first diagnosed AIDS cases in the city. This increase was significant for both sexes, but more pronounced among men. It was concentrated primarily among young adults (aged 25-44 years) and among older children (aged 5-14 years), and most of it was considered to be attributable to AIDS and related infections, tuberculosis in particular. When data were cumulated from 1986 to 1992, approximately 25,000 persons were estimated to have died of AIDS. CONCLUSIONS: The high number of AIDS deaths estimated in Abidjan underlines the heavy toll already paid by African populations, and calls for intensive action.

Country-specific estimates and models of HIV and AIDS: methods and limitations.

OBJECTIVE: This paper presents the methods used to calculate the end of 1997 country-specific estimates of HIV and AIDS produced by the UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance. The objective of this exercise was to improve estimates on HIV/AIDS by using country-specific models of HIV/AIDS epidemics. The paper describes and discusses the processes and obstacles that were encountered in this multi-partner collaboration including national and international experts. METHODS: The 1997 estimates required two basic steps. First, point prevalence estimates for 1994 and 1997 were carried out and the starting year of the epidemic was determined for each country. The procedures used to calculate the estimates of prevalence differed according to the assumed type of the epidemic and the available data. The second step involved using these estimates of prevalence over time and the starting date of the epidemic to determine the epidemic curve that best described the spread of HIV in each particular country. A simple epidemiological program (EPIMODEL) was used for the calculation of estimates on incidence and mortality from this epidemic curve. RESULTS: Regional models that were used in previous estimation exercises were not able to capture the diversity of HIV epidemics between countries and regions. The result of this first country-specific estimation process yielded higher estimates of HIV infection than previously thought likely, with over 30 million people estimated to be living with HIV/AIDS. The application of survival times that are specific to countries and regions also resulted in higher estimates of mortality, which more accurately describe the impact of the epidemics. At the end of 1997, it was estimated that 11.7 million people worldwide had died as a result of HIV/AIDS since the beginning of the epidemic. CONCLUSION: This exercise is an important step in improving understanding of the spread of HIV in different parts of the world. There are, however, shortcomings in the current systems of monitoring the epidemic. Improvements in HIV surveillance systems are needed in many parts of the world. In addition, further research is needed to understand fully the effects of the fertility reduction as a result of HIV, differing sex ratios in HIV infection and other factors influencing the course and measurement of the epidemic.

The impact of city surveillance teams in Bangladesh during the smallpox eradication campaign.

Some of the methods of distribution and collection of information in the city of Dacca, Bangladesh during the Smallpox Eradication Campaign are described. The use of surveillance teams and exchange of information between the city and surrounding countryside are emphasized.

Smallpox surveillance in Bangladesh: II - Smallpox facial scar survey assessment of surveillance effectiveness.

A smallpox facial scar survey of 465 892 persons aged 0-19 years was carried out in Bangladesh in 1976, covering approximately 1% of the 0-19 year old population. Of the 4 306 persons found with facial scarring consistent with previous smallpox infection, none had a history of smallpox with onset after the last reported case on October 16, 1975. Histories taken from persons with facial scars allowed smallpox incidence to be estimated for each year from 1972 to 1975. These estimates indicate that completeness of reporting increased steadily from 11.8% in 1972 to 83.0% in 1975, reflecting the increasing effectiveness of surveillance.

Smallpox surveillance in Bangladesh: I - Development of surveillance containment strategy.

A major epidemic of Variola major with an estimated 90 000 cases and 18 000 deaths occurred in Bangladesh in 1972. During a 3-year period methods of active surveillance (market search, outbreak investigation, and house-to-house search) were developed to supplement the passive reporting system. The percentage of smallpox cases detected increased from 11.8% in 1972 to 83% in 1975. Together with the implementation of improved methods of outbreak control, smallpox transmission was interrupted in October 1975.

The global AIDS pandemic. Toward a new vision of health.

The AIDS pandemic has not been brought under control in any community or nation as its impact continues to worsen. The program-based strategy developed in the mid-1980s was important in placing AIDS on national and global agendas. From the laboratory and healthcare facilities will come many answers to the AIDS pandemic, some opening new prospects for effective prevention and care. The global fight against AIDS has now reached a critical stage in which complacency and loss of direction threaten the opportunity to effectively curb the course of the pandemic, mitigate its impact, and stimulate the emergence of a modern concept of health and society.

Ethical considerations related to the provision of care and treatment in vaccine trials.

Ethical principles of beneficence and justice combined with international human rights norms and standards create certain obligations on researchers, sponsors and public health authorities. These include treatment provision for participants enrolled in clinical trials of vaccines, drugs and other new preventive and curative technologies and methods. However, these obligations are poorly defined in practical terms, inconsistently understood or inadequately applied. Vaccine clinical trial designs normally define standards of prevention applicable to the population where the trial is to take place. The present document addresses specifically the setting of standards applicable to care and treatment in vaccine trials. The lack of clear guidance on how to achieve the optimal synergy between the development of new health technologies, on the one hand, and the promotion and protection of ethical and human rights principles, on the other, is a barrier to the progress of health research and therefore to the advancement of public health. The World Health Organization and UNAIDS have engaged in a series of consultations in Africa, the Americas, Asia and Europe to reflect on how this aim could best be achieved. This document highlights the outcome of these consultations. It proposes a structured approach to consensual decision making in the context of the clinical trial of vaccines against such public health challenges as HIV and newly emerging or threatening epidemics. A structured approach involving investigators and sponsors in a consultative process with trial communities and other stakeholders in research will ensure that the needs and legitimate expectations of trial participants are appropriately met, obligations towards them are delivered and, as a result, ethical research is facilitated in the interest of public health.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations.

Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the world's most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.