Facilitating interaction between TB and AIDS medical services for better management of patients with co-infections.

The Newly Independent States inherited two vertical services for tuberculosis (TB) and AIDS control from the Soviet Union. TB is an important cause of morbidity in the Central Asia Region (CAR). In recent years, HIV epidemics started growing rapidly, especially among injection drug users. TB is the most common AIDS-related opportunistic infection, leading to early deaths among AIDS patients and increased transmission of TB in the general population. An assessment carried out between March 2005 and May 2005 revealed that TB and AIDS services in CAR rarely interacted for the management of patients with co-infections. Following the assessment, the USAID-funded CAPACITY Project promoted cooperation between TB and AIDS services in Uzbekistan, Tajikistan, and Kyrgyzstan. For the first time, representatives from the Ministries of Health and Justice, national and regional TB and AIDS centres, international organizations, and local non-governmental organizations (NGO) gathered to discuss mechanisms for linking TB and AIDS services to address the growing needs of co-infected patients. Technical Working Groups (TWG) established through this cooperation developed linkages between TB and AIDS services. These groups developed protocols, guidelines, and training programmes. Hundreds of medical specialists, health managers, and monitoring and evaluation specialists were trained and national teams of trainers were built. TB/HIV model sites were designed in each country and the models were implemented to test and refine the approaches for patients with co-infections. Key to the success of the approach has been the emphasis on wide participation from all stakeholders. Upon completion, successful models will be advocated for funding and national scale-up.

The HIV/AIDS epidemic in Ukraine: its potential social and economic impact.

Present and immediately foreseeable medical knowledge suggest that HIV infection cannot be avoided by vaccination and that an affordable cure for the resulting syndrome, AIDS, is a long way off. There is a strong possibility that Ukraine is confronted by an HIV epidemic which will spread into the general population and that the most common mode of transmission will be through heterosexual intercourse. The epidemic in the Ukraine is currently concentrated among intravenous drug users. It is estimated that between 60,000 and 180,000 people may currently be infected. In present economic and social circumstances there are many features of Ukrainian society that may add to the probability of the epidemic becoming widespread in the general population. It is likely that this process may have already commenced. The result of this will be numerous additional deaths and illness over the short (5 year) (19,000-23,000 deaths), medium (10-15 year) (61,000-111,000), and longer terms (>20 year) (in excess of 40,000-160,000 deaths). The research reported here was undertaken in 1997-8 and describes the potential medium to long term social and economic impact of an HIV/AIDS epidemic in Ukraine. Using the concepts of risk environment, susceptibility and vulnerability, it reports the problems which might be expected to develop in relation to care of excess orphans, the elderly, vulnerable households and regions as well as among those working in the "third sector", a social sector upon which exponents of the importance of developing sound "civil society" in "transitional economies" place heavy emphasis.

[An HIV prevalence study by means of sentinel epidemiological surveillance among injection narcotic abusers in Saint Petersburg]. / Izuchenie rasprostranennosti VICh metodom dozornogo épidnadzora sredi potrebitelei in''ektsionnykh narkotikov v Sankt-Peterburge.

The data on the study of the spread of HIV infection among injecting drug users in St. Petersburg, carried out by the method of the random testing of blood remaining in used syringes, are presented. Injecting drug users visiting buses working in accordance with the program "Buses for Assistance to Drug Addicts" were chosen as a study group. The exchange of syringes was one of the elements of this program. The work was carried out in two areas with a high concentration of drug users. The eluates from syringes used by 300 persons were studied. The average rate of the spread of HIV in the cohort under study was 12%. The results were indicative of a high degree of the spread of HIV among injecting drug users in St. Petersburg. Epidemiological patrol surveillance proved to be an effective method for the evaluation of the epidemiological situation in a highly inaccessible group of the population.

[The UNAIDS strategy in the prevention of HIV/AIDS in the countries of Eastern Europe]. / Strategiia IuNEIDS po profilaktike VICh/SPIDa v stranakh Vostochnoi Evropy.

Grounds for the necessity of the formation of effective approaches to the prevention of HIV epidemic with a view to counteract the rapid spread of infection in East European countries are presented. Attention is specially drawn to fact that the epidemic will not be limited by drug users, but will quickly cross the boundaries of this group. The development of preventive measures must be based on the use of the world experience. New effective approaches to work with vulnerable groups (the strategy of harm reduction, work in communities, consultations, etc.) must be widely used. The program of actions of the UNAIDS European Section, stipulating the strengthening and extension of the potential of the countries in the region for the effective counteraction to the epidemic, is formulated. As priority areas, activities covering vulnerable groups and with young people have been determined. The strategy of UNAIDS is realized through 20 UN theme groups on HIV/AIDS in the countries of Eastern Europe. Special attention is drawn to the creation of methodological networks. The creation of a unified strategic plan for counteraction the epidemic of HIV/AIDS is regarded by UNAIDS as its perspective for the future.

[The reduction of the HIV vulnerability of women involved in the sex business in Ukraine through social mobilization and the creation of self-support networks]. / Snizhenie VICh-uiazvimosti zhenshchin, vovlechennykh v seks-biznes na Ukraine, putem sotsial'noi mobilizatsii i sozdaniia setei samopodderzhki.

The importance of making plans on projects and measures, aimed at the prevention of HIV infection and the social development of female sex workers (FSW) with due regard to observing the principles of human rights protection, is discussed. The materials and resolutions of the First International Conference "Social Development of HIV-Vulnerable Groups of Population", held of Kiev on December 26, 1998, are presented. The conference was attended by representatives of state and public organizations, specialists on the organization of the prevention of HIV and sexually transmitted diseases among FSW, lawyers, physicians and representatives of the HIV-vulnerable target group (FSW) from 7 Ukrainian cities and from Belarus. All these activities contributed to the implementation of the Project "FSW Network Initiative with NGOs" in 11 Ukrainian cities, starting from September 1999, with the support of UNAIDS. The possibility of the mobilization of FSW for organizing self-support groups with a view to protect their rights and to take themselves measures for HIV/AIDS prevention among FSW is shown.

The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.

OBJECTIVE: To describe recent patterns and trends in the HIV epidemic in eastern Europe. METHODS: AIDS programme managers and epidemiologists of 23 countries were contacted and requested to provide national HIV surveillance data. Joint United Nations Programme on HIV/AIDS/World Health Organisation country fact sheets were reviewed and analysed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished travel reports and expert evaluations. RESULTS: The cumulative number of HIV cases reported in the region increased more than fivefold between 1995 and 1997, from 9111 to 46573; Ukraine, Russia and Belarus accounted for about 90% of all new cases. Dramatic increases in the number of HIV-infected injecting drug users (IDU) were reported from these countries, and a similar pattern was emerging in Moldova, the Baltic States, the Caucasus and Kazakstan. In central Europe, the increase in the number of cases was much lower, and (with the exception of Poland) homosexual transmission was most common, whereas in the Balkan countries, cases due to heterosexual transmission were reported relatively more frequently. At the end of 1997, more than 50% of all cases region-wide had been reported from IDU. HIV prevalence data were inconclusive. The number of reported syphilis cases had risen significantly in the countries of the former Soviet Union. CONCLUSION: Our data confirm that HIV must have been rapidly spreading among IDU in several countries of the former Soviet Union, whereas central and southeast Europe have so far escaped a more extensive spread of HIV. Factors that might have fuelled a massive spread among IDU include changes in drug demand and supply, migration and specific local drug production and consumption patterns. High rates of syphilis reported in the countries of the former Soviet Union highlight that subregion's increased vulnerability with regards to a further spread of the epidemic, via heterosexual intercourse, into the general population.

Community based survey of STD/HIV infection among commercial sex-workers in Calcutta (India). Part-III: Clinical findings of sexually transmitted diseases (STD).

On physical examination of 418 sex workers, 202 (48.32 per cent) were found to have vaginal discharge, which was found to be most common among younger age class. Endocervical pus, genital ulcer, and swelling of inguinal lymph glands were observed in 13.16, 6.22 and 1.91 per cent of the sex workers respectively. Clinically 16.51, 15.31, 11.96 and 4.78 per cent were found to suffer from candidiasis, trichomoniasis, cervicitis and syphilis respectively.

Community based survey of STD/HIV infection among commercial sex workers in Calcutta (India). Part-IV: Sexually transmitted diseases and related risk factors.

Community based survey on a sample of commercial sex workers in one red light area of Calcutta, was carried out to determine prevalence of sexually transmitted diseases (STD) including HIV infection and related risk factors. An alarmingly high prevalence of STDs (80.56 per cent) but low HIV-seropositivity (1.13 per cent) was observed. Candida albicans, Neisseria gonorrhoeae and Trichomonas vaginalis were detected in 23.24, 13.24 and 11.11 per cent of genital specimens respectively. BY TPHA test 62.97 per cent of the sera were reactive for Treponema pallidum. Duration in the profession of sex workers was found to have an association with seropositivity for syphilis. Prevalence of HIV infection might be low at present, but conditions were highly favourable for rapid spread of infection.

Community based survey of STD/HIV infection among commercial sexworkers in Calcutta (India). Part I. Some social features of commercial sexworkers.

A community based sample survey of sexually transmitted diseases and Human Immuno deficiency Virus infection was carried out among commercial sex workers of a red-light area in Calcutta. In this paper socio-demographic aspects of sex workers are discussed. For the survey, 450 sex workers were selected by random sampling method. Among the sex workers surveyed, 84.89 per cent were in the age group 15-29 years. Lowest age was 13 years and mean age was 23.12 years. Large number of sex workers were from Nepal (15.11 per cent) and Bangladesh (11.78 per cent). About 38 per cent were from three districts of West Bengal bordering Bangladesh. About 84.44 per cent of the sex workers were illiterate. Extreme poverty forced 49.10 per cent to choose this profession and family disturbances led 21.56 per cent to this profession. Almost all sex workers (448) had addiction, alcohol being taken regularly by 81.11 per cent. Number of clients of sex workers varied from 2 to 10, average being 3. About 67.33 per cent gave history of pregnancy, 46 per cent had abortion and 41.11 per cent had living children. About 27.11 per cent took precaution against pregnancy regularly. Use of oral pills was found to be the most common practice against pregnancy (13.65 per cent), followed by ligation (11.56 per cent). Only 1.11 per cent reported that their clients used condom regularly.

Community based survey of STD/HIV infection among commercial sex-workers in Calcutta (India). Part II. Sexual behaviour, knowledge and attitude towards STD.

A community based sample survey of STD/HIV infections was carried out among 450 commercial sex workers, (CSW) of one red light area in Calcutta. In this paper, sexual practices of sex workers, their knowledge about sexually transmitted diseases (STD) and practice of preventive and curative measures against STDs, is described. Vaginal intercourse was the usual sexual practice. But as many as 74.44 per cent also practised oral sex. About 82.67 per cent had the practice of washing external genitalia with antiseptic solution after sexual intercourse. About 69.11 per cent of sex workers were aware of sexually transmitted diseases and 30.67 per cent had knowledge about AIDS. About 70.22 per cent had symptoms related to genital tract during one year preceding the survey and 34 per cent of sex workers took medical treatment during last one month.

AIDS-case surveillance.

PIP: In 1991 in India, the Ministry of Health realized that the diagnostic and reporting network for AIDS cases was inadequate as AIDS cases grew and that the establishment of specialized AIDS units in hospitals was not the best strategy. It decided to integrate AIDS diagnostic and management facilities into primary health services. It would arrange training for 1 physician from each district and peripheral hospital, private hospital, and inpatient service of other medical institutions in AIDS diagnosis and management. These physicians would then train others in the clinical diagnosis and management of AIDS cases. The physicians would use the World Health Organization [WHO] case definition of AIDS supported by HIV serological test results. All AIDS cases would be transferred to the Medical College Hospitals of the States and Union Territories (UTs), regional hospitals, and perhaps some private hospitals. Between May 1986 and October 1993, India had 459 AIDS cases reported from 19 States and UTs, especially the States of Tamil Nadul and Maharashtra. This AIDS case surveillance system should motivate political will, describe the underlying and preceding HIV epidemic, and contribute to the understanding of current and future course of the epidemic. Thus, it will guide decision makers to develop sound preventive strategies, to plan health care, and to evaluate interventions. The surveillance system's target population is all outpatients and inpatients at medical institutions. During 1993-1994, 1000 hospitals should make up the network of referral institutions. AIDS case surveillance coordinators (ASCs) at each institution form the basis of the network. The individual case record of each suspected AIDS case will have details on his/her life and medical history. Records of confirmed cases will be sent to State ASCs who will compile them for the National AIDS Control Organisation. After 3-4 year of training and practice in AIDS diagnosis and reporting, AIDS reporting will be integrated into the routine disease reporting system.^ieng

Monkey pox in humans: current results.

The presented studies were performed at the WHO Collaboration Center for Smallpox in Moscow in the framework of the WHO monkey pox project. The authors recommend improved methods for rapid detection of orthopoxvirus antigen, namely passive haemagglutination (PHA) using dried stable red blood cells and ELISA in order to provide more rapid and efficient laboratory diagnosis under field conditions. Independent serologic diagnosis of monkey pox by ELISA-adsorption (ELISA-A) was proved of value for epidemiological studies and for detection of inapparent infections. The application range of the latter technique and its limitations were also determined.

[Human monkey pox: its clinico-epidemiological characteristics]. / Obez'ian'ia ospa cheloveka: kliniko-épidemiologicheskaia kharakteristika.

During the course of the smallpox eradication programme, a new eruptive disease clinically resembling smallpox was discovered in Zaire. The disease, which was named monkeypox after the virus, is a zoonosis occurring sporadically in countries of western and central Africa with tropical rain forest. The studies carried out in Zaire from 1980 through 1985 showed that monkeypox affects mainly children in relatively small remote villages whose population has traditionally frequent contacts with wild animals. Apart from the wildlife, the virus can be transmitted from man to man, but among other sources of infection sick persons did not exceed 20%. Presumed human transmission has occurred in 38 out of 61 outbreaks of human monkeypox and only once reached the third and once the fourth generation; the transmission in all affected villages under observation has extinguished itself. Considering the sporadic and relatively rare occurrence of the disease and expected complications following the immunization with vaccinia which protects from monkeypox, introduction of mass vaccination in the areas at risk is hardly justified at present.

Monkeypox virus: ecology and public health significance.

Recent investigations have revealed that monkeypox virus infections occur with a high prevalence in several species of squirrels belonging to the genus Funisciurus, less frequently in squirrels of the genus Heliosciurus, and rarely in forest-dwelling primates. These squirrels commonly inhabit the secondary forests around human settlements in the rural areas of Zaire, especially where oil palms are grown, and are rare in the primary rain forest.Human infection with monkeypox virus occurs most frequently in the 5-9-year-old age group, particularly in small villages where the children hunt and eat squirrels and other small mammals. As the populations are now increasing in number and can no longer feed on wild life alone for their animal protein requirements, the development of animal husbandry as a source of meat will certainly decrease the risk and the incidence of human monkeypox, even in areas where monkeypox virus is present in the local population of squirrels.Although population growth and economic development in western and central Africa will probably reduce the risk of human infection with monkeypox virus, visitors to these areas who are likely to come into contact with wild animals should be offered smallpox vaccination as a protection.

The role of squirrels in sustaining monkeypox virus transmission.

When the research on the ecology of monkeypox virus entered the latest stage in 1984, three groups of animals were considered priority candidates for maintenance of virus circulations in nature because of their relatively higher population density: terrestrial rodents, squirrels, and gregarious bats. Following the isolation of the virus from a wild squirrel in 1985 another survey was carried out in Bumba zone of Zaïre in January-February 1986, which included collection of animal samples, later on tested by WHO collaborating laboratories. No antibodies were found in 233 rodents tested. A high prevalence of monkeypox-specific antibodies (24.7%) found in 320 squirrels of Funisciurus anerythrus species suggested that these animals sustain virus transmission in the areas surrounding human settlements. A consistently high level of antibody prevalence found among squirrels Heliosciurus rufobrachium suggested that this species is also steadily involved in the transmission. The squirrels, the only mammals frequently infected by monkeypox in the areas of human activities, which are frequently trapped by the population, are obviously a major source of infection for human beings. Out of 39 primates collected during the survey from the primary forest, three were found seropositive for monkeypox. At the moment, however, it is difficult to say whether the primates play an important role in sustaining virus transmission in nature, or (like human beings) that they are an occasional host of the virus. Possibilities are discussed of monkeypox virus transmission being sustained by squirrels outside the areas of major human activities.

Ten years of freedom from smallpox: lessons and experiences. Dedicated to the tenth anniversary of worldwide freedom from smallpox.

Many lessons and experiences were learned during the global programme of smallpox eradication, the most important being those which could be generalized and applied to other health programmes. This does not mean imitating or implementing smallpox eradication techniques to other diseases, since each infection requires its own strategy. It is difficult to dissect out the single key element or to equate the various factors responsible for the success, as these always worked together, in combination, depending one on others. For global eradication, the element of essential importance was international cooperation and close coordination of activities between nations. This would be impossible without proper mechanisms dedicated to international cooperation in the field of health, provided by the World Health Organization, which also assured mobilization of world resources for national programmes and application of appropriate techniques across international borders. The established specific, practical and measurable goals, objectives and targets made every programme worker clearly understand what was to be accomplished and to find his own role in achieving these objectives. Operational techniques had to be flexible, modified appropriately from country to country to make them suitable to present epidemiological situations, local administrative and health structures as well as to demographic and geographic patterns. It was the effective system of surveillance and outbreak-containment that ultimately proved to have been the key to eradication. However, application of skillful management, sound epidemiological principles, advanced technology and adequate logistic support contributed significantly to the achievement of the final goal.(ABSTRACT TRUNCATED AT 250 WORDS)

Monkeypox virus in relation to the ecological features surrounding human settlements in Bumba zone, Zaire.

Since monkeypox virus was discovered in animals in 1958 and in man in 1971, several efforts have been made to identify the reservoir of the virus in nature. In July 1985 a study on human environments and animals suspected to maintain virus transmission was carried out in northern Zaire. The study revealed three well demarcated areas: the human settlement area, the agricultural area and the primary tropical rain forest. The first two were found inhabited by terrestrial and arboreal rodents and bats, while the larger animals have abandoned them. Data on human morbidity collected in the preceding years suggested that most of the patients were infected either in the settlement or in the agricultural area. Isolation of the virus from a squirrel confirmed this suggestion and proved, on the other hand, that the virus could circulate in an area deprived of the larger wild animals, including primates. The virus isolation and results of serologic testing suggest that out of three groups of animals inhabiting the agricultural area, the squirrels Funisciurus anerythrus should be considered a priority candidate to sustain virus transmission.

Smallpox and its post-eradication surveillance.

PIP: Since May 1980 when the 33rd World Health Assembly declared the global eradication of smallpox, WHO has been developing a comprehensive system of surveillance aimed at maintaining the world permanently free from this disease. By 1984, all countries had ceased vaccinating the general public against smallpox, and had withdrawn the requirement for smallpox vaccination certificates from international travellers. A number of countries had also discontinued the vaccinating of military personnel. Until now WHO has maintained a stock of smallpox vaccine sufficient to vaccinate 300 million persons, but considering that 10 years have elapsed since the last endemic case of smallpox, maintenance of this reserve is no longer indicated. WHO continues to monitor rumors and coordinate the investigation of suspected cases, all of which have actually been misdiagnosed chickenpox or some other skin disease, or other errors in recording or reporting. Variola virus is now kept in only 2 WHO Collaborating Centers which possess high security containment laboratories. Since the variola virus gene pool has been cloned in bacterial plasmids which provide sufficient material to solve future research and diagnostic problems, there is no need to retain stocks of viable variola virus any longer. The results of a special program for the surveillance of human monkeypox have confirmed that the disease does not pose any significant health problem. In addition to testing human and animal specimens, WHO collaborating laboratories have made progress in the analysis of DNA of orthopoxviruses and in the development of reliable serological tests.^ieng