Should HIV be on the development agenda?

PIP: According to estimates, there are 33.6 million people living with HIV and a further 16.3 million have died since the early 1980s. In addition, around 16,000 people are being infected each day, 90% of them in sub-Saharan Africa and in the developing countries of Asia. It is noted that HIV is a challenging problem to solve, with the virus deduced as elusive and evasive from a technical and virological point of view. Social and economic factors are indicated as determinants of HIV, as well as associated with the spread of the virus. Hence, effective national programs against HIV often require dramatic cultural shifts and confronting longstanding taboos. To this effect, there is a need for the international community to advocate political and organizational behavior change, persuading governments to invest in order to prevent huge financial and human losses. Moreover, development agencies should incorporate work to diminish general vulnerability to HIV and raise HIV up on the political agenda, be that at a local, provincial or national level.^ieng

An actual use comparison of condoms meeting Australian and Swiss standards: results of a double-blind crossover trial.

The performance of condoms in actual use has been poorly researched in the past, especially in comparing condoms that met different quality control standards as indicated by laboratory testing. The present study used a double-blind crossover design to compare the performance of 2 types of condoms in actual use; one that met the Australian and International Organization for Standardization (ISO) standards for condom quality and one that met the more stringent Swiss Quality Seal requirements. Ninety-two men recruited from Metropolitan Melbourne completed a self-report diary sheet after each condom was used which assessed the performance of the condom and the conditions under which it was used. From a total of 1917 condom uses, there was an overall breakage risk of 2.7%. The breakage risk ratio (Australian/ISO:Swiss) for all types of use was 1.16 (95% confidence interval 0.68-1.99). When subanalyses by method of entry were performed, the condoms meeting the Swiss standard appeared to fare better than the Australian/ ISO standards for anal sex (RR = 4.84, 95% CI 1.07-21.8, P = 0.022), while the opposite was the case for vaginal sex (RR = 0.74, 95% CI 0.35-1.53, P = 0.41). The result for anal use was statistically significant at the 5% level, despite being based on fewer condom trials than that for vaginal use, but this result needs to be replicated. Although the participants appeared representative of the general male population in Melbourne in the age bracket 18-46 years, there was a significant history of condom usage reported. This may have influenced the risk of breakage.

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.

AIDS prevention and care in Asia and the Pacific: what has Australia to offer?

PIP: Australia's response to the HIV epidemic has 4 major features. 1) Communities and individuals at risk have been encouraged to explore their risk factors and actions which they could take to increase their safety. Thus, treatment and care has been integrated with prevention in ways which allow people with AIDS to make contributions. 2) National, state, and local policies have concentrated on harm reduction and have deemphasized traditional moral concerns about sex behavior or IV drug use. Harm reduction policies reflect reality rather than what society views as ideal behavior. 3) A working consensus has been maintained between infected and affected groups and the community at large. 4) Finally, many political and strategic risks have been taken, mistakes have been made, and lessons learned from those mistakes. An inclusive, multisectoral, and multilevel program has been forged by debate and disagreements which were resolved rather than denied. Australia's approaches to HIV which could be transferred to other countries include the analysis of sexual and drug-using behavior in various communities; the provision of interpersonal, peer, and collective education along with condoms, needles, and syringes; and data provided by national and state laboratory and epidemiological networks. The sense of collaboration which has dominated the diverse groups seeking a national response to HIV in Australia is lacking on the international level where interagency brawling is the norm. With the incidence of newly-infected persons falling from 16/100,000 in 1987 to 8/100,000 in 1991, the lessons learned in Australia may well provide much needed answers in other countries.^ieng

Confronting the HIV epidemic in Asia and the Pacific: developing successful strategies to minimize the spread of HIV infection.

PIP: In Asia, the cumulative total of HIV-infected adults will reach 1.22 million by 1995, and, by 2000, the number is estimated to reach 11-45 million. The modes of transmission vary from country to country and include injecting drug users, commercial sex workers and their clients, commercial blood donors, hemophiliacs, and homosexuals. Social, cultural, and health factors also affect transmission, such as rites of passage to adulthood, lack of female autonomy, multiple sex partners, wars and civil unrest, and availability of drugs. The HIV epidemic has economic ramifications and causes, e.g., migrant worker camps, the sex industry, and rapid urbanization luring Burmese girls to Thailand. Governments must create an environment for behavior-change through financial, political, and legislative measures. Community organizations also play a role in prevention, as in programs initiated by a squatter settlement in Bangkok, where 36% of IV drug users were found to be HIV-positive. In Maharashtra State, India, peer-based prevention programs were developed for sex workers. Successful behavior change of individuals is based on redefinition of peer norms, understanding the danger and vulnerability to infection, and building confidence to change behavior. Successful programs require placing priority on HIV issues on the political agenda, negotiation and consensus-building skills, and competent program management. For instance, in Zimbabwe a project enlisted 380,000 people in 4500 education sessions within 2 years, and distributed 2.5 million condoms. Among sex workers, condom use increased from 5% to 50%. Implementation strategies include the provision of information and interpersonal education. In Zaire, mass media and social marketing efforts boosted condom sales from less than half a million in 1987 to over 20 million in 1991. The means to change behavior requires the availability of good quality condoms, disinfectants, and syringes. Furthermore, clinical management of gonorrhea, syphilis, human papillomavirus, and chancroid is vital to lowering the risk of HIV transmission. Continuous epidemiological research and the evaluation of prevention programs improve program effectiveness.^ieng

An endemic strain of Staphylococcus haemolyticus colonizing and causing bacteremia in neonatal intensive care unit patients.

Coagulase-negative staphylococci are now the major cause of bacteremia in neonatal intensive care units. To date, coagulase-negative staphylococci causing neonatal infections have been found to be distinct when typed by standard techniques. To determine whether or not an endemic strain could be identified using more discriminatory techniques, we characterized coagulase-negative staphylococci isolates obtained from a prospective study of coagulase-negative staphylococci bacteremia in a neonatal intensive care unit during 1984 through 1985, by standard techniques supplemented with DNA-DNA hybridization and restriction endonuclease analysis. We typed 58 strains that were isolated from 52 episodes of bacteremia in 38 neonates. There were 46 isolates of Staphylococcus epidermidis. Three pairs of strains were identical, and each strain was from a different patient. There were 12 isolates of Staphylococcus haemolyticus. Ten were identical, referred to as strain TOR-35, and had been isolated from eight different infants. Characterization of strains obtained in 1986 from a prospective study of coagulase-negative staphylococci-colonizing neonates admitted to the same neonatal intensive care unit found the TOR-35 strain had colonized 6 of 17 neonates by day seven. A point prevalence survey of all neonates in the same neonatal intensive care unit in 1990 found 5 of 30 neonates to be colonized with the TOR-35 strain. Therefore, we were able to identify an endemic strain of S haemolyticus that caused multiple episodes of bacteremia during a 6-month period and remained present in the same environment for a 5-year period.

Cervical cytology in central Australian Aboriginal women.

Cervical smears were taken from 113 Aboriginal women who attended an Aboriginal community controlled health service in Alice Springs for gynaecological, obstetric or other unrelated conditions over a 6 month period. Nine women (8%) had cervical atypia and two (1.8%) had cervical intraepithelial neoplasia. These rates are similar to those observed among other population groups in larger Australian and overseas studies, as was the high prevalence of abnormal smears in women under 25 years of age (11% of this age group). Urban dwellers had a higher prevalence of abnormal smears (15%) compared with town camp and rural women (2%). This pilot study emphasises the importance of routine screening for central Australian Aboriginal women and identifies possible risk groups for further research.

The politics of evaluating Aboriginal Health Services.

Evaluation of Aboriginal Health Services (AHSs) has become a topic of importance to service providers and governments in recent years. This paper examines some of the difficulties AHSs have in conducting evaluation and presents an example of an inappropriate evaluation methodology as proposed by the Commonwealth Department of Aboriginal Affairs (DAA) in 1986. The paper examines the contradictory nature of the DAA proposal and the mistrust it has engendered in many AHSs. It then highlights some of the political difficulties in developing meaningful national and community health objectives as a basis for sound evaluation of health services. The paper concludes by identifying some of the processes whereby more appropriate evaluation methodologies might be developed and suggests that negotiation and consultation with the Aboriginal communities and their health services are imperative to successful evaluation.