Training in intensive care medicine.

Training in Intensive Care Medicine is currently undergoing extensive changes, with the introduction of a new curriculum and new examinations. This article explains the new pathways for training in Intensive Care, with specific reference to trainees in Acute Medicine.

Ammonia-hydrogen bromide and ammonia-hydrogen iodide complexes: anion photoelectron and ab initio studies.

The ammonia-hydrogen bromide and ammonia-hydrogen iodide, anionic heterodimers were studied by anion photoelectron spectroscopy. In complementary studies, these anions and their neutral counterparts were also investigated via ab initio theory at the coupled cluster level. In both systems, neutral NH(3)...HX dimers were predicted to be linear, hydrogen-bonded complexes, whereas their anionic dimers were found to be proton-transferred species of the form, (NH(4)(+)X(-))(-). Both experimentally measured and theoretically predicted vertical detachment energies (VDE) are in excellent agreement for both systems, with values for (NH(4)(+)Br(-))(-) being 0.65 and 0.67 eV, respectively, and values for (NH(4)(+)I(-))(-) being 0.77 and 0.81 eV, respectively. These systems are discussed in terms of our previous study of (NH(4)(+)Cl(-))(-).

Demography and economics of HIV/AIDS.

The rapid spread of HIV in the 1980s and 1990s in the non-industrialised world is now leading to an AIDS epidemic. This in turn is having a demographic and economic impact on these societies. This article assesses the most recent evidence for these impacts. It concludes that, while there is already a real and measurable impact, there is far worse to come. The demographic consequences will be particularly serious. Economic impact is rather more uncertain, and the article looks at the macro-economic impact as well as that on firms. In addition, it is postulated that economics may not be the most appropriate discipline to assess the true effects of the disease.

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.

The economic impact of AIDS in Africa.

The experience of acquired immune deficiency syndrome (AIDS) in Africa is very different from that in the developed world. In the West, AIDS affects few people, and for those who are infected, it is an increasingly manageable illness. In Africa, huge numbers of people are being infected - mainly young adults through sexual intercourse. This is having a dramatic effect on key demographic indicators. Child mortality in some countries has doubled, while up to 25 years of life expectancy have been lost. The economic impact of AIDS is difficult to establish, but it is certainly leading to increased poverty in African families and communities. Development advances are being reversed, but the impact is incremental rather than catastrophic.

The real challenges: the orphan generation and employment creation.

PIP: A baby born to an HIV-positive mother has close to a 100% chance of being orphaned before reaching the age of 10. In South Africa, nearly 1 million children under the age of 15 are projected to lose their mothers by 2005 due to AIDS. These orphans are less likely to receive adequate parenting, education, and nutrition; others will seek to survive on the streets and thus will be more likely to face sexual abuse and exploitation. The long-term impact of HIV/AIDS on both the children and society will be severe. The orphans that AIDS is creating pose serious social, economic, political, and developmental challenges for South Africa. There are two options left for the government: 1) dramatically increasing welfare grants and staffing of welfare departments in order to care for the orphans; 2) find new imaginative measures of meeting the challenge. In addition, provision of employment for its population is another challenge the region is facing. Having the required resources and infrastructure, a potential intervention for South Africa would be training and employing a new cadre of workers to care for AIDS orphans. This type of response would also help build a civil society.^ieng

The World Bank discovers AIDS.

PIP: In 1999, the World Bank published a strategic plan demonstrating the next steps in its endeavor against AIDS. "Intensifying Action Against HIV/AIDS in Africa--Responding to a Development Crisis" calls on the World Bank and its partners, as well as African governments, to make a new commitment to sparing millions of people from HIV/AIDS. This paper identifies the limitations of the report, including the paucity of data, the lack of success stories, and the manner of data presentation. Although it is able to give five examples of benefits of action, there are still better ones, more recent, more sustainable, and more applicable to the African setting. It is essential to see whether actions spelled out in the strategic plan would be implemented, and advocacy works and programs be developed. What matters most, after all is reducing the spread of HIV and dealing with the impact of AIDS.^ieng

AIDS in Africa: demographic and socio-economic impacts.

PIP: In the current absence of an easy-to-implement technical solution to check the spread of HIV, the social, economic, and development determinants of society must be examined in order to better focus technical efforts. The world is experiencing not so much an AIDS epidemic as it is the arrival of a deadly disease which will be with humankind for a long time. It is unclear whether the UNDP development indicators, the human development index and the human poverty index, are too sensitive to the impact of AIDS. Despite the complex relationship which exists between HIV/AIDS and its social and economic causes and consequences, the importance of the socioeconomic environment for the spread of HIV is not appreciated and interventions are largely not located in Africa. Achieving development goals will, however, go a long way toward stopping AIDS and its consequences. The socioeconomic correlates and causes of HIV, biomedical factors, sexual behaviors, the socioeconomic environment, macrofactors, interventions, the demographic and development consequences of AIDS, and the demographic, economic, and development impacts are discussed.^ieng

How the transport sector drives HIV / AIDS and how HIV/ AIDS drives transport. Economic impact: Southern Africa.

PIP: A close connection exists between mobility and the spread of HIV infection. Being away from home and traditional social networks and constraints makes people more likely to have sex partners other than their spouses or regular partners. The transport sector has an important role in facilitating the movement of people. Indeed, improving transport is a developmental goal worldwide, with an efficient transport system seen to be a necessary precondition to economic growth. The role of the transport sector in facilitating the spread of HIV needs to be considered. South Africa has the greatest length of roads, railways, and the most registered vehicles in southern Africa. In 1997, Johannesburg International Airport became Africa's most busy airport. South Africa also has a considerable maritime transport sector. In 1994, an estimated more than 500,000 people were employed in the country's transport sector. The following risk groups must be targeted in order to control the spread of HIV in South Africa: people working in building and maintaining infrastructure; people who work in the railways, roads, airlines, and shipping services; transport sector managers; and passengers.^ieng

Monitoring the AIDS pandemic.

PIP: Monitoring the AIDS Pandemic (MAP) Network, established in 1995, is comprised of technical experts from 40 countries and a range of disciplines who assess the trends and pandemics of global HIV/AIDS. Preliminary to the 1998 World AIDS Conference in Geneva, MAP members met to draft a report to present to conference participants and then to post on the Internet. The report notes that the AIDS epidemic in Africa is not uniform. In some southern African cities, 45% of women seen at antenatal clinics are HIV-infected--10 times more than in most central and western African cities. There is an urgent need for data collection and analysis to identify the factors underlying such discrepancies. Specific areas addressed in the report include migration and HIV, inequities in care and support, vertical transmission, HIV transmission in health care settings, AIDS orphans, tuberculosis and HIV, and neglected behaviors such as increasing injecting drug use in some African cities. The collection of epidemiologic data should now become the responsibility of UNAIDS. In preparation for the next World AIDS Conference, MAP should focus on identifying gaps in existing data and how they can be filled.^ieng

How HIV / AIDS impacts on the health sector.

PIP: The HIV epidemic is largely under control in the developed world, with a small number of cases which will not increase. The health sector in developed countries must now treat individuals infected with HIV as effectively as possible with currently available medical knowledge and technology. However, in the developing world, the large number of patients will grow to seriously affect the health care sector in many ways. The health sector is generally not preparing for the effect HIV will have upon it. The structure of the health sector, the demand for health care, the burden of morbidity, access, the supply of health services, stress and burn-out, ethical issues, staff training and replacement, HIV-infected staff, the impact of economic austerity, the quality of health services, and community and home care are discussed.^ieng

The demographic and economic impact of AIDS in Africa.

PIP: Knowing how HIV/AIDS will affect the demography and social and economic functioning of societies is of extreme importance if planners and policy-makers are to effectively respond to the pandemic and avert its potentially devastating consequences. Problems in predicting the implications of the AIDS epidemic are considered, followed by discussion of the anticipated demographic consequences in terms of mortality, fertility, population size and growth, dependency ratio, and orphans. The economic effect is then considered with regard to households, firms and enterprises, and the macroeconomic impact. Overall, the AIDS epidemic will reverse hard-won development gains and make people and countries worse off. The effects may last for decades. Since many adults who are dying at relatively young ages have children, an entire generation of these orphans may grow up without the care and role models they would otherwise typically have.^ieng

Coping with the burden.

PIP: At a time when the burden placed by HIV/AIDS on health systems, communities, and individual families is steadily increasing, policies such as structural adjustment and health reform are reducing health budgets. HIV-related chronic illness and deaths among health workers have further exacerbated pressures in the health sector and remaining staff suffer from stress and burnout. Factors contributing to stress among health workers in Africa and other developing countries include inadequate knowledge and support for treating HIV-related illnesses, lack of a safe blood supply, the terminal nature of HIV infection, lack of training in dealing with death and dying, discomfort discussing sexuality with patients, the social stigma associated with HIV/AIDS, and fears of occupational exposure to HIV. Since AIDS affects all areas of life, it requires a coordinated response from the health sector, education, social services, legal institutions, and religious and community groups.^ieng

AIDS in India: lessons for Southern Africa.

PIP: While no national serosurveillance data are available on India, 2,872,527 blood samples have been screened for various reasons. 45,866 of these samples tested positive for infection with HIV. In 38.3% of cases, HIV infection is thought to have occurred through heterosexual intercourse, 9.9% from receipt of infected blood products, 4.9% through IV drug use, and only 0.4% through homosexual relations. 17.3% are suspected cases and 28.3% fall into the "others" category. The author codirected a workshop on the socioeconomic impact of HIV/AIDS in India with the goal of sensitizing the corporate sector to the seriousness and magnitude of the HIV/AIDS epidemic and the need for urgent action in India. 71% of workshop participants felt that AIDS would be a problem in the next 5 years for their company or organization. A surprising number of companies in India have dread disease insurance policies with usually generous benefits. However, as Indian corporations adopt a more profit-oriented approach and downsize, HIV/AIDS costs will increasingly be shifted to the state. Lessons learned from India's experience may help South Africa manage its HIV/AIDS epidemic.^ieng

Vancouver AIDS conference: special report. A verdict on the conference: sadly, not one world or one hope.

PIP: Although the theme of the 11th International Conference on AIDS held in Vancouver during July 7-12, 1996, was "One World, One Hope," developed and developing countries have HIV/AIDS epidemics of different magnitudes, different levels of resources with which to combat the problems, and dissimilar objectives. The latest data released at the conference report an estimated 21.8 million people to be currently living with HIV/AIDS, the vast majority of whom live in developing countries. 84% of the estimated 7.7 million AIDS cases which have occurred since the beginning of the pandemic were in Africa or Asia; only 9% were in Europe and the US. The greatest burden of disease is and will be therefore experienced in the developing world which, relative to the developed world, has extremely limited resources. The epidemic continues to spread throughout much of the developing world, while levels of HIV infection in the developed world are largely remaining constant, with the center seemingly moving more into marginalized groups such as the homeless, drug users, and other groups. A whole range of new drugs will soon be available to treat HIV/AIDS among those who can afford them. It is possible that AIDS may simply become manageable as a chronic illness in the west. Such drugs, however, will be prohibitively expensive for almost all people infected with HIV. Moreover, the side effects of these new drugs remain to be seen, and it is possible that individuals will develop resistance to the treatment. The author laments the lack of papers at the conference analyzing the impact of the epidemic and hopes to see more representation and consideration of the developing world at the next conference, to be held in Geneva in 1998.^ieng

Vancouver AIDS conference: special report. Rwandan refugee camps: NGOs get rough treatment from both sides.

NGOs attempting to grapple with the thankless task of helping the Rwandan refugee camps have come in for some rough treatment from two directions over their HIV/AIDS efforts. At the policy level, an AMREF paper presented to the Vancouver conference charges bluntly that "There is no policy regarding HIV/STDs in refugee camps among international organizations specializing in refugee crises; thus there is absence of STD drugs and protocols, no privacy in open (tent) clinics, no means of protection (no condoms), and no information regarding STDs/HIV." AMREF bases its comments upon its experience among 700,000 Rwandan refugees in camps in West and North-West Tanzania, an area where (AMREF remarks pointedly) there was previously a low prevalence of HIV by Tanzanian standards, at 2-5%. At the operational level, CARE International, in a conference paper, reported rough treatment at the hands of the Rwandans themselves. It has been working under contract from AIDSCAP among the 400,000 Rwandans who fled to the Ngara district of Tanzania. Not surprisingly, it found that women and girls in the camps faced a higher risk than men. But more surprisingly at first sight, it found that after its HIV educational efforts "negative attitudes about condom use increased from 22% to 78%," which was possibly explained by "political ideology." "Young Hutu men in the camps boasted of their efforts to impregnate as many women and girls as possible to help replenish the population."

Vancouver AIDS conference: special report. AIDS and development: the tangled nexus between economic growth and social equality.

PIP: Economists have written papers on their belief that the HIV/AIDS epidemic could adversely affect macroeconomic growth in countries with high levels of HIV infection. It has, however, recently become apparent that while HIV and AIDS may affect economic growth, the effect may be small and extremely difficult to measure. Moreover, there is a growing debate over whether purely economic indicators are the most appropriate ones by which to measure development. The United Nations Development Program has proposed an alternative indicator, the Human Development Indicator (HDI), derived from life expectancy at birth, the adult literacy rate, mean years of schooling, and an adjusted measure of per capita income. Participants at the Vancouver AIDS Conference addressed the question of where the impact of the HIV epidemic will be felt. Biological, cultural, and structural co-factors and development projects, and HIV/AIDS in Southern Africa are discussed.^ieng

Vancouver AIDS conference: special report. The role of the military: to protect society -- and themselves.

PIP: Military personnel are at particularly high risk of becoming infected with HIV because they are in the age group at highest risk for infection, age 15-24 years; they are away from home for long periods of time; many feel invulnerable and ready to take risks; there are usually prostitutes and drugs in military areas; and troops have cash, but maybe not condoms, in their pockets. The level of attention given to HIV/AIDS in the military has grown over the course of the last few international AIDS conferences. One roundtable on HIV/AIDS in the armed forces was held at the 11th International Conference on AIDS held in Vancouver during July 7-12, 1996. A large-scale survey reported at the conference found the level of sexual activity to be significantly higher among US military personnel than in the civilian population. Even the oldest soldiers reported higher levels of multiple partner sex habits than the most sexually active young men in the UK and France. The data further indicate that significant numbers of those men who were infected continued to knowingly have unprotected sex. Data from Angola, Cambodia, Cameroon, the Central African Republic, Congo, Cote d'Ivoire, Thailand, and Zimbabwe show significantly higher levels of HIV infection among military personnel compared to the civilian populations. The authors stress the important role the military can play in preventing the spread of HIV and the need to involve military personnel in AIDS prevention programs.^ieng

Vancouver AIDS conference: special report. The global business response to AIDS: what is a "business-like" response, and is business responding enough?

PIP: Approximately 40 businesses were represented at a 2-day meeting held immediately before the main Vancouver conference on the Global Business Response to AIDS. Only three companies were from the developing world, with the overwhelming majority being from Canada and the US. Companies in countries where many people are infected with HIV and where the number of AIDS cases is rapidly growing must be concerned about HIV/AIDS. However, in countries of low-level HIV prevalence and infection incidence, businesses may have less concern about HIV/AIDS unless their own employees are infected. Even then, the priority a company gives to coping with the HIV/AIDS pandemic will be determined largely by the importance of the positions of the infected employees. Businesses discussed whether HIV/AIDS merits special attention, the undesirability of screening prospective employees for HIV infection, company size and the ability to respond to the needs of sick employees, the roles of business in society, the general failure of businesses to incorporate HIV/AIDS issues into the mainstream of company operations, how businesses are coping with the HIV/AIDS epidemic, and the need for governments to form a regulatory framework in which businesses can work. Conference participants discussed which steps should be taken next and prepared a declaration for conference organizers, including a mission statement for the global business response to AIDS.^ieng