Role of national dermatology societies: A perspective from Tunis.

Dermatology in French-speaking African countries is facing many challenges. Dermatology societies, if they exist, are relatively young and have limited financial resources to provide regular training opportunities for their members and those in training. In several sub-Saharan nations, the small number of dermatologists is truly alarming with the prevalence of such major skin diseases as cutaneous leishmaniasis, AIDS, mycetoma, leprosy, and the consequences of skin bleaching procedures, reaching catastrophic figures.

Setting targets for HIV/AIDS-What lessons can be learned from other disease control programmes?

In a Collection Review, Richard Hayes and colleagues discuss metrics for assessing progress in control of the HIV/AIDS epidemic in the context of prior disease control programmes.

Behavioral surveillance survey regarding human immunodeficiency virus/acquired immunodeficiency syndrome among high school and junior college students.

BACKGROUND AND AIMS: It is necessary to know the baseline knowledge, attitude, and practices about human immunodeficiency virus/acquired immunodeficiency syndrome among young people and the changes in these with intervention to guide prevention efforts. METHODS: A cross-sectional pre- and post-survey with health education as a method of intervention was carried out in four different randomly selected schools and junior colleges among the Class IX-XII students of both sex. Instrument developed by the World Health Organization (WHO)/UNAIDS in their best practice recommendations was used for data collection. RESULTS: Knowledge about all correct methods was present in 61.23% of the respondents. Knowledge of at least two methods of prevention was present in 70.31% of the respondents. Misconceptions about prevention were that good diet (33.42%), avoiding mosquito bite (49.71%) and avoiding public toilets (65.14%) could help in the prevention. With intervention, there was an improvement in the knowledge. However, the proportion of students with misconceptions did not come down. Correct knowledge about two methods of prevention also did not reach the WHO recommendation of 90%. CONCLUSION: It is very difficult to change the attitude and practices by a single health educational intervention and an ongoing behavior change communication is recommended.

Immunity, immunopathology and vaccines against HIV?

Immunity and immunopathology of HIV infections leading to AIDS are reviewed from an evolutionary point of view. Accordingly infectious agents and host defences have co-evolved to reach balanced states where virus and host survive. While HIV has not quite yet reached an optimal balance, tuberculosis (TB), leprosy, HBV, HCV in humans or lymphocytic choriomeningitis virus (LCMV) in mice have successfully established persistence. These non- or poorly-cytopathic infections infect the next host usually before or at birth while hosts are immunoincompetent. They also infect immunocompetent hosts to persist at low levels concomitant with an ongoing T and B cell immune response that is repeatedly triggered by latent or persistent infection of extralymphatic or lymphatic host cells. This infectious or infection-immunity is the basis for cellular immunoprotection by antigen activated T cells. Because we cannot imitate this infection-immunity long-term and cannot build polyspecific vaccine combinations covering all possible neutralising variants yet, vaccines against TB, leprosy, HCV and HIV only protect transiently and incompletely.

Effective tuberculosis control and health sector reforms in Kenya: challenges of an increasing tuberculosis burden and opportunities through reform.

During the period from 1980 to 1997, the annual number of new tuberculosis cases increased four-fold in Kenya, and had reached approximately 50,000 cases by 1998. During the same time period, the government per capita expenditure on health dropped from US$9.5 to US$3.5. Since 1983, Kenya has been decentralising financial responsibility and decision-making power to the districts. In addition, the late 1980s saw the introduction of cost-sharing schemes for most health services, excluding tuberculosis (TB) treatment. In the midst of these changes, a dual epidemic of TB and HIV/AIDS emerged, and is presently over-burdening the traditional public health system. In response, the National Leprosy and Tuberculosis Control Programme (NLTP) is seeking a wider network of service providers and new approaches to the prevention and treatment of TB in the country. The history of health sector reform in Kenya is summarised and the role of the NLTP in these reforms assessed. Recent approaches taken by the NLTP to sustain effective TB control, which draw on the environment of a changing and flexible health system, are expressed. Participation of the NLTP in components of health sector reform, particularly decentralisation, integration, financing through cost-sharing and public/private mix, are highlighted.

Towards a strategy of universally efficacious vaccination against pathogens uniquely susceptible to cell-mediated attack.

Infection by some intracellular parasites is contained only by cell-mediated immunity, and yet antibody is produced at the expense of the cell-mediated response upon natural infection, leading to chronic or fatal disease. Effective vaccination must therefore generate an immunological imprint ensuring a strong and stable cell-mediated response upon infection. Such diseases include leprosy, tuberculosis, the leishmaniasis and AIDS (Kaplan and Cohn (1986) Int. Rev. Exp. Pathol. 28, 45-78; Surcel et al. (1994) Immunology 81, 171-176; Pearson et al. (1983) Rev. Infect. Dis. 5, 907-927; Clerici and Shearer (1993) Immunol. Today 14, 107-111). BALB/C mice are susceptible to Leishmania major, a protozoan that causes cutaneous leishmaniasis in man, by the criterion that substantial infection results in antibody production and progressive disease (Locksley and Scott (1991) Immunoparasitology Today, A58-A61; J.N. Menon and P.A. Bretscher, unpublished data). Infection of BALB/C mice with very few parasites results in an exclusive cell-mediated, Th1-like response and resistance to an ordinarily pathogenic, high dose challenge. This resistance is associated with a strong and stable cell-mediated response (Bretscher et al. (1992) Science 257, 539-542; J.N. Menon and P.A. Bretscher, unpublished data). The generation of this Th1 imprint by low dose infection has been achieved with three very different strains of the parasite. There is a similar dependency of susceptibility and resistance on relative parasite dose in 'susceptible' and 'resistant' mice and in mice of 'intermediate susceptibility'. For example, 'resistant' mice are resistant to substantial infection but succumb to infection with very high doses of parasites. We therefore propose that infection of a genetically diverse population with a very low dose of viable parasites, that does not induce antibody in any individual, will either induce cell-mediated immunity and contain the parasite, or the parasite will grow until it reaches the threshold required to induce cell-mediated immunity, thereby generating the required imprint. Low dose infection may thus constitute universally efficacious vaccination. The pertinence of these observations to improving the efficacy of BCG vaccination against tuberculosis is discussed.

Women and AIDS in Zambia: a review of the psychosocial factors implicated in the transmission of HIV.

Women are at high risk for HIV infection in Zambia. There are several interrelated factors to account for this including the economic, cultural and educational status of women. This paper explores these factors and suggests that these factors need to be thoroughly understood before preventive strategies are designed and implemented.

PIP: Women comprise the largest single grouping of human immunodeficiency virus (HIV)-infected persons under 30 years of age in Zambia--a phenomenon that reflects a complex interaction of economic, cultural, and psychosocial factors. Although women represented only 30.4% of clients presenting for HIV testing at a Lusaka site, 52.6% were seropositive compared to 35% of the male attendees. The low status of women in Zambia is perpetuated by early marriage and childbearing, low levels of education, unemployment or restriction to the informal sector, and polygamy. Only 2% of married Zambian women use condoms, and their financial dependence and low status render them unable to negotiate safe sex with partners. The Zambia National Acquired Immunodeficiency Syndrome (AIDS)/Sexually Transmitted Diseases (STD)/Tuberculosis and Leprosy Program's strategic plan for 1994-98 recognizes women's special vulnerability to HIV. It proposes educational interventions targeted at commercial sex workers and women attending prenatal and STD clinics as well as improved access to condoms. To achieve the sustained behavioral changes required to reduce HIV transmission, however, women's low status--particularly the lack of educational opportunities--must be addressed and women must be empowered to believe they can make choices about their sexual practices.