30 MARCH 2012, VOLUME 13, ISSUE 13

Health workers manning five health centres in two refugee camps in the southwestern Ugandan district of Isingiro say they are overwhelmed by the high number of refugees and local residents in need of HIV services. Severe personnel shortages in Nakivale and Oruchinga refugee settlements have led to long queues at the clinics and placed a heavy burden on the few health workers available, many of whom often have to take double shifts to meet demand. "It's the same staff to do ward work and carry out sensitization and awareness campaigns to increase the refugees' understanding of HIV/AIDS, and how to prevent transmitting the disease," said Dr Chris Omara, health coordinator for Medical Teams International (MTI), a medical NGO that works in humanitarian emergencies. MTI runs two clinics of its own and supports three government health centres in the settlements. Some 180 health workers, only three of whom are doctors, are responsible for a population of over 139,000 people - 63,749 refugees and more than 76,000 local residents -- in the area, which has an HIV prevalence of 6 percent...

Dr Isaac Odongo, MTI's regional programme manager for southwestern Uganda, noted that the need for information on HIV and sexually transmitted infections (STIs) was crucial for refugees, many of whom came from conflict-prone areas of the Democratic Republic of Congo (DRC) where such information was hard to come by. "The HIV infection rates are generally low among the refugees when they just come [but] with time, they get into reckless activities [unprotected sex] with locals and they get infected," he said... At one of the health centres in Nakivale refugee settlement there are 69 HIV-exposed infants who need close monitoring and supervision. However, the health centre has only one general doctor, Dr Gideon Ndaula, who has to see HIV-positive people as well as other patients, and the same scenario is repeated in health centres across the settlement. On the day IRIN/PlusNews visited the facility, Ndaula was performing male circumcisions and was unable to attend to other patients. Uganda's Ministry of Health has embarked on a large-scale voluntary medical male circumcision programme as part of HIV prevention efforts.

Despite the broad availability of HIV treatment in Canada, stigma, shame, and denial remain barriers to proper treatment and care, physicians and advocates say. People who know they have HIV and still do not seek treatment increase their risk of transmitting the virus as well as dying prematurely. "They don't want to look themselves in the mirror and say 'I'm HIV-positive,'" said Dr. Anne Stewart, a family doctor and medical director of Casey House, an HIV/AIDS palliative care hospital in Toronto. "So they don't test, don't get treatment, avoid dealing, and they'll come to you 10 years into their disease with complications of AIDS which, in this day and age, is a travesty." It is not known how many who test HIV-positive do not seek treatment. However, a 2011 Ontario study found one in 10 men and one in 14 women had not sought viral-load testing within a year of their new diagnosis. Earlier this month, a US study found one in four people with HIV do not stay in care... To help patients stay in care, recently published recommendations by international experts suggest assigning newly diagnosed patients a "navigator" to guide them through the health care system, as well as a nurse or case manager for follow-up; providing one-on-one counseling; and using automated devices to alert doctors when patients drop out of care for six months or longer.

Reported condom use among sexually active Canadians ages 15-24 rose from 62 percent in 2003 to 68 percent in 2009-10, Statistics Canada said recently. In the 2009-10 Canadian Community Health Survey, two-thirds of respondents ages 15-24 reported having had sex at least once, which was not a significant change from the 2003 survey. Sexual activity was reported by 30 percent of those ages 15-17; 68 percent by ages 18-19; and 86 percent of those ages 20-24. No significant change from 2003 was found for those reporting first sex before age 15 (9 percent) or those reporting first sex at ages 15-16 (about 25 percent). Condom use declined with age, from 80 percent among ages 15-18 to 63 percent for those ages 20-24. The decline in usage may have to do with how condoms are viewed, said Dr. Ashley Waddington, an OB/GYN at Queens University in Kingston. Younger age groups tend to rely on condoms for birth control, while Canadians moving through their 20s tend to form longer-term, more-committed relationships and use other forms of birth control, she said. In more stable relationships, young adults do not perceive unprotected sex as still being an STD risk factor, agreed Sarah Flicker, an adolescent and sexual/reproductive health expert at York University in Toronto. "One of the things we should be doing is teaching our kids and young adults that it's really important to think about using birth control and condoms," Flicker said. "That's the best way to both prevent pregnancy and [STIs] to keep them safe." "You could be with them for six months already, but they could be carrying something that they've had previously and be asymptomatic," said Waddington.

Year-end data from the state Department of Health show a continued rise in HIV/AIDS in South Florida. While revised federal counting methods instituted last year have artificially inflated some of the increases, officials say the new figures still highlight an ongoing epidemic. New HIV cases rose by 21 percent statewide, and about half the diagnoses were made in gay and bisexual men. New HIV cases increased 25 percent in Broward County and 30 percent in Palm Beach County, while new AIDS cases there rose by 6 percent and 8 percent, respectively, according to state data. The 1,040 new HIV cases logged by Broward County last year represent an infection rate of 59 cases per 100,000 residents, up from around 55 in 2010. The county's distinction as having the nation's highest infection rate since 2008 has attracted the attention of CDC officials, who have begun planning a major anti-AIDS initiative with local officials. Palm Beach County in 2011 recorded 407 new HIV cases, for a rate of 30.7 per 100,000. "I think it's leveling off, and hopefully it's going down in some of the heavily impacted groups like African Americans and Hispanics," said Dr. Mitchell Durant, the county's HIV/AIDS program supervisor.

Given the calls for the elimination of the informal international personnel system that awards the presidency of the World Bank to an American, President Obama was under some pressure in selecting a replacement for Robert Zoellick, the capable executive who is retiring in June. The president needed to find a nominee known not so much for political connections in Washington as for a demonstrated ability to carry on the bank's mission of fostering development, especially in the poorest countries. We believe Mr. Obama has done just that in choosing Jim Yong Kim, a physician who has dedicated most of his career to delivering health care to destitute people worldwide. Dr. Kim, who has been president of Dartmouth College since 2009, is a departure from the World Bank's previous presidents in more ways than one. He is the first person of Asian descent to be nominated; Dr. Kim was born in South Korea and immigrated to the United States at the age of 5. Previous presidents have been bankers, politicians or, like Mr. Zoellick, technocrats who have previously served in government. Dr. Kim is the first nominee who has dedicated himself to development work, both in academia and in practice.

With fellow physician and Harvard professor Paul Farmer, Dr. Kim founded Partners in Health, an organization created to deliver quality health care to some of the world's poorest people, including in Haiti, Peru and Rwanda. One of its innovations was to enlist the poor themselves in the delivery of their own health care. Later, at the World Health Organization, Dr. Kim oversaw an expansion of the delivery of anti-retroviral drugs to combat HIV to 3 million more people in the developing world. Under Mr. Zoellick, the World Bank has demonstrated that it still has a role to play in a world where some developing countries attract abundant private capital. It remains a vital resource for the poorest nations; Mr. Zoellick saw through a capital increase that allowed the bank to help some of those countries through the global recession. As Columbia University economist Jeffrey Sachs, a candidate for the World Bank position, pointed out, "at its best, the bank serves as a powerhouse of ideas and a meeting ground for key actors who together can solve daunting problems of poverty, hunger, disease and environmental degradation." Mr. Sachs withdrew his candidacy on Friday, strongly endorsing Dr. Kim. The U.S. nominee may still face challengers from other nations; three African governments are backing Nigeria's finance minister, Ngozi Okonjo-Iweala. But those who would reject an American nominee ought to consider whether the United States should be entirely excluded from leadership roles in international organizations. As it is, Americans are ruled out in competitions for the head of the International Monetary Fund and secretary general of the United Nations. While it would be well if the top jobs at international organizations were treated as open to all candidates, it's also important that highly qualified nominees not be ruled out -- even if they happen to be American.

Mistakes, goofs and outright deceptions litter the scientific literature, but there is something that can be done about it. Scientists, writers and journal editors gathered at Rockefeller University in New York last evening to discuss increases in retracted research over the past several years and how best to correct the research record. "Image manipulation is not a new phenomenon, but it is an increasingly visible one," said Liz Williams, executive editor of the Journal of Cell Biology (JCB), a Rockefeller University Press journal that has led the way in ferreting out manipulated images before their publication. She was one of three panelists that I helped to bring together for the latest Science Online New York City (SONYC) event, hosted by nature.com and Rockefeller University... Not every manipulation will raise a red flag, but as many as 50% of papers require at least one figure to be redone because it did not conform to standards...

John Krueger works as a scientist-investigator at the Office of Research Integrity (ORI) in Rockville, Maryland ... talked about growth in retractions, ... but concluded that this doesn't likely represent a rise in misbehaviour. Rather, it reflects the hundreds of thousands of extra eyes on every paper that can help to check for things such as image manipulation or plagiarism, both of which may eventually lead to a retraction (but don't necessarily have to -- some instances are innocuous). "Each paper is now reviewable in perpetuity," he says.. Ivan Oransky, executive editor with Reuters and co-founder with Adam Marcus of the blog RetractionWatch, carried on the theme, discussing retractions and their negative effects on different fields of science... He credits the success of the blog (it covered about two-thirds of retractions published last year) not only to the editors' own desire to follow certain topics but also to tips from the community. Oransky argues that readers online will increasingly become a force for rooting out publication anomalies that may reflect fraud or just sloppiness, creating, in effect, a sort of post-publication review of papers. He also pointed out approaches, such as pre-peer-review publishing efforts modelled after the physics preprint server arXiv, and a new product still in testing, called Crossmark, that treats a paper as a constantly evolving thing aided by input and comments from the community. He pointed out that anyone can help to be part of the solution.

...By 2022, reformed healthcare systems in African countries could succeed in making quality care available to a majority of their citizens, given the political will to meet healthcare spending targets, according to a new report by the Economist Intelligence Unit (EIU). 'The Future of Healthcare in Africa' report, commissioned by Janssen Pharmaceutica NV and released Thursday, focuses on five possible future scenarios for African healthcare systems over the next 10 years and gives high... Thirty four leading healthcare experts, representing the entire chain of stakeholders across the sector, helped the EIU's expert analysts identify the key trends shaping African healthcare systems and these were used to develop scenarios that depict the possible health landscape on the continent in 2022, said a press release by The Economist...

In Africa, Janssen is active in many ways. Apart from selling its products across the region via its offices in Algeria, Egypt and South Africa, and working with distributors elsewhere, the company has also set up a number of projects specifically designed for infectious and neglected diseases. The projects include research for a new tuberculosis treatment in collaboration with the TB Alliance, a microbicide targeting HIV, with the International Partnership for Microbicides, a new research programme against elephantiasis and river blindness with the Drugs for Neglected Diseases initiative (DNDi) and the Gates Foundation, as well as against sleeping sickness, Chagas and visceral leishmaniasis. For products that are already approved, Janssen sets up access programmes, such as the recently concluded agreements with generic manufacturers in Africa to manufacture and distribute the company's HIV/AIDS compounds, or the free distribution of treatments against intestinal infections with the Children Without Worms programme... With regard to medicines, specific initiatives can be taken which could benefit the region, according to the Janssen group chair, [Jane] Griffiths, [who] added: "Regulatory harmonisation for the approval of medicines should be high on the agenda in Africa. Some of our HIV medicines have delayed market access because of different requirements across the region. "Counterfeiting is also a scourge, and we have started with a pilot project with the Nigerian authorities to check how patients can verify the product's authenticity through text messaging. Technology options could mean a lot in the continent."

A new survey of commercial sex work in Kenya, the first to include male sex workers, has revealed that 40 percent of female and male commercial sex workers are in marriages or stable unions. According to the survey by the National AIDS and Sexually Transmitted Infections Control Programme (NASCOP), the World Bank, Kenya Prisons and Canada's University of Manitoba, there are an estimated 200,000 commercial sex workers in Kenya, 15,000 of whom are men. The study, which covered all the country's urban areas with the exception of North Eastern Province, found that Rift Valley and Nairobi provinces had the biggest number of sex workers. "[A] majority of the male commercial sex workers have sex with men, and this puts them at greater risk because anal sex, as is already known, is a catalyst for the spread of HIV, and because of the stigma involved, many do not seek services like HIV testing," said Nicholas Muraguri, head of NASCOP... "Their spouses or girlfriends or boyfriends do not know they are engaged in commercial sex work, which puts marriages and stable unions at even greater risk of HIV," he pointed out.

The survey did not asses the level of condom use between sex workers and their clients, but Muraguri told IRIN/PlusNews initial studies had shown that "The level of condom use between them [sex workers] and their clients is just slightly above 50 percent, which is worrying. Sex workers tend not to use condoms with their regular clients." According to the Kenya HIV Prevention Response and Modes of Transmission Analysis, 2009, commercial sex workers and their clients together contribute 14 percent of all new HIV infections, while men who have sex with men and prisons account for 15.2 percent... Muraguri said the government has recognized the need to create safe access to HIV services for often marginalized high-risk groups. "These are groups that continue to operate secretively because there are no safe conditions for them," he said. "We must provide this [access] either within the law or through change in societal mentality to ensure they receive services to save them and the general population."

Utah Gov. Gary Herbert on Friday vetoed a controversial bill banning public schools from teaching contraception as a way of preventing pregnancy and sexually transmitted diseases. The bill, which also sought to bar instruction on homosexuality or other aspects of human sexuality other than the teaching of abstinence, would have been the first of its kind in the nation if it had become law. It had previously cleared Utah's Republican -- controlled House and Senate, and Herbert was widely expected to sign it. In vetoing the measure, dubbed HB 363, Herbert said that as a parent and grandparent he considered proper sex education in public schools an important component to the moral education youngsters receive at home. "If HB 363 were to become law, parents would no longer have the option the overwhelming majority is currently choosing for their children. I am unwilling to conclude that the state knows better than Utah's parents as to what is best for their children," he said. "In order for parents to take on more responsibility, they need more information, more involvement, and more choice not less. I cannot sign a bill that deprives parents of their choice," he added. Supporters of the bill argued that sex education was best left up to parents.

In the Morocco of the 1980s, where homosexuality did not, of course, exist, I was an effeminate little boy, a boy to be sacrificed, a humiliated body who bore upon himself every hypocrisy, everything left unsaid. By the time I was 10, though no one spoke of it, I knew what happened to boys like me in our impoverished society; they were designated victims, to be used, with everyone's blessing, as easy sexual objects by frustrated men. And I knew that no one would save me -- not even my parents, who surely loved me. For them too, I was shame, filth. A "zamel." Like everyone else, they urged me into a terrible, definitive silence, there to die a little more each day. How is a child who loves his parents, his many siblings, his working-class culture, his religion -- Islam -- how is he to survive this trauma? To be hurt and harassed because of something others saw in me -- something in the way I moved my hands, my inflections. A way of walking, my carriage. An easy intimacy with women, my mother and my many sisters. To be categorized for victimhood like those "emo" boys with long hair and skinny jeans who have recently been turning up dead in the streets of Iraq, their skulls crushed in. The truth is, I don't know how I survived. All I have left is a taste for silence. And the dream, never to be realized, that someone would save me. Now I am 38 years old, and I can state without fanfare: no one saved me...

Today I grow nostalgic for little effeminate Abdellah. He and I share a body, but I no longer remember him. He was innocence. Now I am only intellect. He was naive. I am clever. He was spontaneous. I am locked in a constant struggle with myself. In 2006, seven years after I moved to France, and after my second book, "Le rouge du tarbouche" (the red of the fez), came out in Morocco, I, too, came out to the Moroccan press, in Arabic and French. Scandal, and support. Then, faced with my brother's silence and my mother's tears on the telephone, I published in TelQuel, the very brave Moroccan magazine, an open letter called "Homosexuality Explained to My Mother." My mother died the next year. I don't know where I found the courage to become a writer and use my books to impose my homosexuality on the world of my youth. To do justice to little Abdellah. To never forget the trauma he and every Arab homosexual like him suffered. Now, over a year after the Arab Spring began, we must again remember homosexuals. Arabs have finally become aware that they have to invent a new, free Arab individual, without the support of their megalomaniacal leaders. Arab homosexuals are also taking part in this revolution, whether they live in Egypt, Iraq or Morocco. They, too, are part of this desperately needed process of political and individual liberation. And the world must support and protect them.

Annual new cases of HIV/AIDS in South Africa have fallen by half since 1999, and a new study credits this improvement largely to a dramatic rise in condom use. The proportion of South African men ages 16-24 who reported condom use during their last sexual encounter increased from 20 percent in 1999 to 75 percent in 2009, according to the study. While acknowledging the contribution of improved access to antiretroviral treatment, the authors cited increased condom use as the "most significant factor" in reducing new infections. South Africa comprises 0.7 percent of the global population but 17 percent of all people with HIV/AIDS. Nearly 6 million people among the country's population of 50 million live with HIV/AIDS. Approximately 2.8 million South Africans have died prematurely due to the disease, and more than 1 million children have lost their mother to HIV/AIDS. During the height of the epidemic in 2005, more than 700 South Africans died of AIDS daily, many in their prime. The proportion of South Africans ages 15-49 who are HIV-positive, 17 percent, is more than triple the rate for all sub-Saharan Africa, while worldwide adult prevalence is 0.8 percent. Although antiretrovirals were not made available publicly until 2004, in excess of 1.5 million South Africans now receive them, helping boost life expectancy from 54 years in 2005 to 58 years in 2010. The study, "The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: A model-based analysis," was published early online in the Journal of the Royal Society Interface.

The U.S. Senate has approved a bill that will make it easier for early stage companies to raise money by broadening the number of people that can invest in them and help companies file for initial public offerings. But will it mean more biotechnology startups will have the money to survive the multiyear journey to bring their therapeutics or drugs to the finish line of regulatory approval and commercialization? Or will it lead to more companies competing for smaller amounts of money? James Greenwood, the president and CEO of the Biotechnology Industry Organization, said the Jumpstart Our Business Startups bill would make it easier for small, emerging biotechnology companies to raise money and reduce the hurdles that stymie them. "These reforms are especially important to innovative biotechnology companies that do not yet have product revenue and must spend investor dollars on compliance rather than the search for cures and breakthrough medicines," Greenwood said in a statement. Greenwood said: If burdens on public financing were removed, private investors would have greater certainty that the companies they help take public will have the chance to succeed. This confidence hopefully will lead to increased investments in promising science that could lead to treatments and cures for some of the most debilitating and life-threatening diseases...

The government has teamed up with Ethiopia' s main employees' and employers' associations to launch a new HIV/AIDS workplace policy that is to be implemented across the nation. The new policy came into force in January 2012 and will be applied across the board in state and private organizations. It is expected to protect job seekers from mandatory HIV tests, while facilitating voluntary counselling and testing and defending the right of employees living with HIV to medical leave or job re-allocation. It also provides guidelines for the establishment of an AIDS fund to help employees cope with living with the virus. The new policy is in line with the country's goal of halving new HIV infections by 2015... According to a 2009 study, "Managing HIV and AIDS in the workplace" by the NGO, Stop AIDS Now, most NGOs admitted that they did not have the skills to develop an HIV/AIDS workplace policy. "NGOs do not have concrete knowledge of the costs of developing and implementing a workplace policy, and most respondents worry that all activities for responding to HIV in the workplace have financial implications by increasing overhead costs. Furthermore, they are not sure of the sustainability of such undertakings," the report noted...

The new policy brings an agreement with the Ethiopian Employers Federation and the Confederation of Ethiopian Trade Unions, and is also endorsed by the Ethiopian Privatization and Public Enterprises Supervising Agency, which oversees 53 state organizations. It stipulates that employers will make the necessary investments to ensure universal precautions in workplaces to protect employees from HIV infection, and are also expected to put in place a post-exposure prophylaxis system for their workforce. Employers committed to making available personnel and funds to implement the policy in their businesses, and to facilitate employees' access to condoms and treatment for sexually transmitted infections... The federation brings to the agreement a commitment by around 700 organizations across a broad range of sectors like transport, construction, hotels, airlines, banks, insurance and others, many with their own trade union. Officials at the Confederation of Ethiopian Trade Unions - who developed their own workplace HIV policy in 2001 - expressed relief that employers are now on board... The umbrella organization of over 400 employees' unions and an estimated 400,000 members, says some of its anti-HIV/AIDS campaigns have been failing short because of funding constraints... The AIDS fund will raise a monthly contribution from employees and will also be run with assistance from the organizations' credit and saving associations. Money from the fund will be used for treatment, care and support programmes such as medical checkups and balanced diets, and other social assistance programmes for employees and their families...

According to a statement by the Working Group on Intellectual Property of the Brazilian Network for the Integration of Peoples (GTPI/Rebrip), a coalition of nongovernmental organisations, the judge granted a request by Cristalia, a Brazilian generic producer, to annul a patent held by Abbott Laboratories. The patent was on the drug ritonavir and lopinavir (lop/r), which is marketed under the brand name Kaletra and used to treat HIV infection... Sources said it is likely that Abbott will appeal the decision... A leading feature of the case is that the patent was granted under the "pipeline" process, which allowed "revalidation" of patents granted in other countries while Brazil was modifying its patent law for certain new areas including pharmaceuticals... The pipeline process in Brazil had already come into question in recent years ... and this decision furthers that movement... A global campaign by NGOs was launched last autumn to open rinotavir/lopinavir to generic competition... A patent on the same drug was rejected in India last year... GTPI said the Rio decision could save Brazil millions of dollars through its national anti-HIV programme as the patent meant it could not allow sale of generics despite their availability on the international market. "The price paid by Brazil is US$763 per patient/year, but there are generic versions of approved quality by the World Health Organization (WHO) sold for US$402 per patient/year, a price 47% lower," the group said. Abbott and the Brazilian government had reached an agreement in 2005 for the company to lower its prices on the drug, after the Brazilian government issued a decree declaring it to be of public interest, the first step to a compulsory licence. At that time, the drug consumed some 30 per cent of Brazil's national budget on antiretroviral treatment, GTPI said. Now it represents some 16 per cent of such spending.

Next month, policymakers and researchers will gather at a global health conference to discuss how developing countries can move beyond aid. The Council on Health Research for Development (COHRED) forum, to be held in South Africa in April 2012, will discuss how resource-poor nations can become more self-sufficient. Most importantly, the meeting is based on the premise that they are capable of doing so... According to WHO estimates, less than 60 per cent of people in the developing world have access to generic medicines that are available at a fraction of the cost of brand-name drugs. Like other stakeholders in global health, COHRED has been pushing for some time for African countries to boost their own drug-development capacity -- and this has never been more urgent... There's another reason why African countries should experiment with developing a drugs industry -- the least-developed nations have until 2016 before they are bound by the international agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement), which dictates patent protection for new drugs. With careful negotiation they might be able to extend the deadline, buying precious time to develop the framework for a robust pharmaceuticals industry. One major driver of drug development is the presence of a market -- but most Africans who need essential drugs can't afford them. A recent report by the UN Conference on Trade and Development (UNCTAD) recommends that African countries take steps to ensure a market exists...

With limited initial capacity, countries need to be prudent about which drugs are developed. Different countries have different needs, and selection must be made through dialogue between government ministries, pharmaceutical companies, and local drug regulatory authorities, suggests the UNCTAD report. Good regulation is crucial, yet could prove most challenging. Many African states have patchy regulatory systems for quality assurance and little means to ensure drugs testing follows ethical guidelines. They will need to create and enforce watertight regulations to ensure that substandard or ineffective medicines don't flood the market. A joint report by the WHO, UNCTAD and the International Centre for Trade and Sustainable Development (ICTSD) points out that "local producers find it difficult to meet regulatory standards, including those for WHO prequalification, and medicine regulatory authorities in Africa are not considered to be meeting their own national or international standards." Some African countries are already making moves towards self-sufficiency. In February South Africa announced a US$211 million venture with Swiss therapeutics firm Lonza to manufacture the key chemical components (the 'active pharmaceutical ingredients') of antiretrovirals -- the first time an African country has set out to develop any active ingredients. This is a critical move in the right direction, as South Africa's HIV/AIDS epidemic requires a quarter of all antiretrovirals used worldwide. But the development of a robust pharmaceutical industry in Africa can't, and shouldn't be, uniform. States are extremely varied in their scientific ability, level of manufacturing regulation, and financial capacity to invest. Some countries could first set up a system to simply manufacture drugs based on existing formulations, before progressing to research and development. Others with more advanced biotech industries, such as South Africa, will have the know-how to innovate in drug development. Africa will not bolster its pharmaceutical capacity without considerable incentive -- by subsidising land to build manufacturing plants, for example, or reducing import taxes on chemicals -- from national governments, and perhaps from donors in the short term. It will require extraordinary collaboration between industry and government agencies. But if it works, it will produce the most important set of public-private partnerships yet.

Regulators are increasingly scrutinizing HIV and TB responses in South Africa's mining sector, which could lead to the industry being hit where it hurts -- the bottom line. Speaking to hundreds of mine workers and community members in the mining town of Carletonville on World TB Day, Deputy President Kgalema Motlanthe urged the mining industry to improve TB services by adopting the GeneXpert rapid TB test, upgrading health centres to allow for the treatment of drug-resistant TB, and by extending health services to those from surrounding communities and mines that may have limited access to healthcare. At the same event, Mineral Resources Minister Susan Shabangu announced that mining companies, whose HIV, TB and workplace safety policies are being audited by her department, will have to submit their policies as a prerequisite for renewing their mining licenses. As part of the deputy president's call for all mine workers to be screened for TB and HIV in the next year, World TB Day celebrations were accompanied by HIV and TB screenings, during which at least 1,220 people were examined for TB and 260 people were tested for HIV. Before addressing the crowd, Motlanthe and Shabangu joined other officials, including Minister of Health Dr Aaron Motsoaledi and South African National AIDS Council deputy chairperson Mark Heywood at a community dialogue meeting with about 200 miners, who raised concerns like housing, compensation for their families if they should die, and unfair dismissal following TB diagnoses. Mark Heywood, who also heads the human rights organization, Section 27, encouraged miners to report such dismissals. "In South Africa it is illegal for anyone with HIV or TB to be dismissed or chased away from employment," Heywood told IRIN/PlusNews. "We encourage any mineworker who has been dismissed because of TB or HIV to report it -- to overcome TB we have to protect human rights." As in many countries in southern and East Africa, South Africa's high TB incidence is fuelled by a high HIV prevalence. Although many people carry TB, only 10 percent will ever develop the active disease, but because of their compromised immune systems, people living with HIV are up to 37 times more likely to develop active TB...

A District program that distributes free female condoms in areas of the city with high HIV rates prevented enough infections in its first year to save over $8 million in future medical costs over and above the cost of the program, according to a new study. For every dollar spent on the program, there was a cost savings of nearly $20, according to the study, which appears in the current issue of the journal AIDS & Behavior... The District began its program two years ago to fight a disease that is at epidemic levels. At least 3 percent of Washington residents have HIV or AIDS, a prevalence rate that is the highest for any city in the United States... Officials turned to female condoms to give women more power to protect themselves from HIV and sexually transmitted disease, especially if they cannot get their male partners to use condoms. In the first year, the District gave away 200,000 female condoms at beauty parlors, convenience stores, community clinics and other locations. After two years, nearly half a million have been distributed, health officials said. The project also trained peers, including hair stylists at beauty salons, to make it more comfortable for women to talk about sexual health.

"We found the DC program was practical and doable," said David Holtgrave, one of the study's authors and chairman of the Department of Health Behavior and Society at Johns Hopkins' Bloomberg School of Public Health. The training helped many women and, surprisingly, some men accept the product, officials said. "When we think about what it means for a city or state to have a comprehensive HIV program, this study really says you ought to include female condoms as one element of a comprehensive program because it's acceptable, effective and cost-saving," Holtgrave said... Based on the prevalence rate of HIV and sexually transmitted disease, they calculated the probability of infection, and different scenarios showing the effectiveness of female condoms in protecting against infection. "I think this is a really big deal," said Greg Pappas, senior deputy director at the DC Department of Health and a study co-author. The free condoms give women -- and couples -- an alternative way to address risk, he said. "We're finding very good use and uptake for it," he said. For women who are HIV-positive, he said, "they're saying, 'I can have sex again.'"

Doctors Without Borders (MSF) is warning that extreme cuts to Greece's health budget have led to a spike in HIV/AIDS and malaria among some groups. Reveka Papadopoulos, MSF's country chief, said HIV incidence among injecting drug users in central Athens increased by 1,250 percent in the first 10 months of 2011 compared to the same period in 2010. The rise is largely due to the suspension or cancelation of free needle-exchange programs, she said. "We are also seeing transmission between mother and child for the first time in Greece. This is something we are used to seeing in sub-Saharan Africa, not Europe," Papadopoulos said. "There has also been a sharp increase in cases of tuberculosis in the immigrant population, cases of Nile fever -- leading to 35 deaths in 2010 -- and the reappearance of endemic malaria in several parts of Greece," Papadopoulos added. Following the cuts to the health services budget and a 40 percent reduction in funding for hospitals, Greece's social services are "under very severe strain, if not in a state of breakdown. What we are seeing are very clear indicators of a system that cannot cope," Papadopoulos said. MSF is responding by shifting its support from emergency interventions to those that address basic public health.

Women's declining condom use during their freshman year at college may be connected to instability in their grades and alcohol consumption, reports a new study. The study, involving 279 freshman women at Boston's Northeastern University, found that those with lower grade point averages (GPAs), and a tendency to binge drink more often, reported up to a 10 percent decrease in condom use. "College women often engage in serial monogamy, resulting in multiple partners during the college years, and they are often unaware of their partners' risk," said study leader Jennifer Walsh, a researcher at Rhode Island's Miriam Hospital Center for Behavioral and Preventive Medicine. "This makes continued condom use important for women's health." To assess the behavioral health of college freshmen for the National Institutes on Alcohol Abuse and Alcoholism, researchers questioned the students monthly on their condom use. Usage was measured on a five-point scale from "never" to "always." Additional information was gathered on students' socioeconomic status, substance use, and GPAs. The data demonstrated a shift in condom use -- irrespective of how diligently the students started off. Birth control pills also were shown to contribute to lowered condom use, even though they do not guard against STDs. The report found Caucasian women and those with fewer sexual partners were more apt to use condoms from the beginning than African-American women and women with multiple sex partners. Some women who believed alcohol led to unsafe sex still were generally less likely to use condoms.

New research published in The Lancet, an international medical journal, has revealed that commercial sex workers in Uganda have one of the highest rates of HIV infections in the world. Some 99,878 female sex workers in 50 countries (14 in Asia, four in Eastern Europe, 11 in Latin America and the Caribbean, one in the Middle East and 20 in Africa), were subjects in the study conducted between January 1, 2007 and June 25, 2011. Results of the study, which was led by Dr. Stefan Baral of the US-based John Hopkins School of Public Health, were released on Thursday. The four-year survey funded by the World Bank and the United Nations Population Fund ranked Uganda as one of the countries where sex workers had a higher HIV prevalence than other women. Women who sell sex came sixth among the 20 African countries after Malawi, Zimbabwe, South Africa, Kenya and Benin. An average of four sex workers in ten will have HIV. This rate is about five times more than other women of reproductive age, who have 7.7% prevalence, according to the recent AIDS indicator survey released by the Ministry of Health last week. In addition, the likelihood of new HIV infections among sex workers stands at 15%... Of all the prostitutes in the 50 countries, those in sub-Saharan Africa had the highest HIV prevalence. Only two of the African countries studied, Egypt and Madagascar, had zero HIV rates among women who sell sex. The study, which assessed the burden of HIV compared to that of other women of reproductive age, found that the burden is disproportionately high and concluded that there is an urgent need to scale up access to quality HIV prevention programs for sex workers. State minister for ethics and integrity Fr. Simon Lokodo agrees that like all Ugandans, sex workers have a right to HIV treatment and attention. "However, giving them the leeway to operate as a business is too much to ask from the Government," he said.

Abstract
Background: Vertical HIV programs have achieved good results but may not be feasible or appropriate in many resource-limited settings. Medecins sans Frontieres has treated HIV in vertical programs since 2000 and over time integrated HIV treatment into general health care services using simplified protocols. We analyzed the survival probability among patients receiving antiretroviral therapy (ART) from 2003 to 2010 in integrated versus vertical programs in 9 countries in sub-Saharan Africa.

Methods and Findings: Cox regression assessed mortality and program design association, adjusting for baseline age, body mass index, clinical WHO stage, tuberculosis, program age and setting. The analysis included 15,403 HIV-positive adults on ART in 7 vertical (14,124 patients) and 10 integrated (1279 patients) programs. Cox regression including 14,523 patients followed for up to 30 months ART showed similar outcomes for mortality (adjusted hazard ratio (aHR) 1.02; 95% confidence interval (CI): 0.83 to 1.24) and lower risk of loss to follow-up (aHR: 0.71; 95% CI: 0.61 to 0.83) in integrated compared with vertical programs. The greatest risk of death was from initiating ART at WHO stage 4 (aHR 1.99, 95% CI: 1.74 to 2.29), although greater program experience was protective (aHR: 0.77, 95% CI: 0.66 to 0.89). Risk of loss to follow-up was greater in experienced programs (aHR: 3.33; 95% CI: 2.92 to 3.79) and rural settings (aHR: 3.82; 95% CI: 3.49 to 4.20).

Conclusions: ART delivery in integrated general health care programs results in good outcomes. Compared with vertical HIV programs, patients initiated ART in integrated programs at more advanced stages of clinical immunosuppression yet had similar risk of death and lower risk of loss to follow-up.

In the article by Greig et al from Medecins sans Frontieres, the authors compared data from their supported HIV/AIDS care and treatment programs at 17 sites in 9 countries in sub-Saharan Africa. Initially, their support began as vertical programs, but later they changed to an integrated model that incorporated HIV treatment into general health care services. In this retrospective study (2003-2010), they compared a number of clinical indicators of antiretroviral treatment (ART) outcome, although controlling for a variety of potential confounders. However, a major potential confounder, CD4 count at initiation of ART, was not included due to 30% with missing data. The study included 14,124 patients at 7 vertical program sites and 1279 at 10 integrated sites. All of the integrated sites were rural, whereas 4 of 7 vertical sites were urban. Programs were standardized across both program types. Training and advisory staff were similar for both. A standardized electronic database containing routinely collected data facilitated this study. Follow-up data were censored at 30 months on ART to make the follow-up time equal between the 2 programs. Although the authors used data collected from a large number of sites in multiple countries, they examined only retrospective data and were unable to address specific country contexts and the relative costs of the 2 approaches. However, the study results add useful information to the small body of studies that evaluate the utility of integrated programs compared with vertical programs...

There is clearly a need for more rigorous studies of different strategies to assess integration impact over a wider range of services and settings. Because of varying country contexts, obtaining country-specific data is also important. As noted above, a common robust methodological framework would facilitate comparison across countries. These studies should include economic evaluation and the views of clients which would influence their uptake of integration strategies at the point of delivery. Ideally, studies should also be of sufficient duration to address long-term consequences on quality of care and sustainability. Informed evidence-based decision-making on this issue is needed and will have major impact on future program design and implementation. With future funding for strengthening health care in resource-limited countries likely to be limited, we need to ensure that programs are efficient and provide quality care to patients.

FDA has expanded the indication for etravirine (Intelence) to include treatment of HIV-1 in pediatric patients ages 6 and older in combination with other anti-retroviral medication. The expansion means that the drug is now also indicated for pediatric patients who are experiencing virologic failure with HIV-1 strains resistant to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and other anti-retroviral medications, a statement from manufacturer Janssen Therapeutics said. The approval adds a new, 25-mg dose of the drug, which allows weight-based treatment for pediatric patients. Etravirine was approved in January 2008 as a treatment for adults with resistance to NNRTIs and other anti-retroviral treatments. Approval for the pediatric indication was based on data from the Pediatric trial with Intelence as an Active NNRTI Option (PIANO) study, which measured safety, tolerability, and efficacy of the drug in combination with other anti-retroviral treatment in 101 treatment-experienced HIV-1 pediatric patients ages 6 to under 18 who weighed at least 35.2 lbs... Adverse events include severe skin rash, allergic reactions, change in shape or body fat, immune system change (including tingling, numbness, or pain in hands and feet in adult patients), and diarrhea, which was more common in children.

After performing a review of prospective cohort evaluations, a focussed assessment of the current knowledge base and methodology pertaining to condom effectiveness against sexually transmissible infections, including HIV, was also conducted. Key observations included the point that studies of condom effectiveness are inherently complex and the potential forms of study bias all generally favour the null hypothesis. Perhaps the most challenging obstacle to rigor in these studies lies in determining which events of condom-protected sex occurred before infection as opposed to after infection when, in fact, infection occurs. This problem leads to misclassification bias; however, other sources of misclassification bias are common. Greater attention to the selection of a recall period, improved precision of self-reported measures, and accounting for condom use errors and problems are critical steps that must occur to promote rigor in these studies. Despite multiple shortcomings, prospective studies of condom effectiveness provide a reasonably favourable evaluation. Subsequent studies, however, should be designed to greatly reduce the error variance that predisposes condom effectiveness studies to type 2 errors that mask the potential value of condoms.

Abstract
Objective: To provide an updated review of condom migration as a means of highlighting methodological issues for future studies of this behavioural issue.

Methods: Electronic searches of PubMed, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were carried out in October 2010 and updated in January 2011 for English-language articles published from 1994 onward.

Results: Evidence addressing condom migration from microbicides and vaccines is vastly underdeveloped, simply because these products are still experimental. In contrast, the more advanced evidence regarding male circumcision is hopeful because it suggests that migration may not be an overwhelming issue. Nonetheless, the entire body of empirical evidence on this question could be substantially expanded and improved.

Conclusions: Until stronger evidence suggests that condom migration is unlikely, it is important to be mindful of the potential for condom migration to occur in response to biomedical interventions (circumcision, microbicides and vaccines).

Articles recently published in Addiction have reignited debate about David Nutt's 2009 conflict with the then UK home secretary, Alan Johnson. After Professor Nutt publicly accused the government of ignoring science when formulating drug policy (for example, by overestimating the dangers of Ecstasy), he was sacked as UK drug policy adviser. As with other contentious issues such as heroin prescribing, needle exchange, and sex education, many scientists think that the lesson of the Nutt controversy is that we must take the politics out of health policy decisions and simply "do what the science says." Based on experience as researchers and as policy makers at the White House and United Nations, we argue that although science should inform health policy, it cannot be the only consideration... Scientific research is an extremely valuable tool for informing health policy decisions because it can identify emerging problems, offer tools to tackle those problems, and forecast the likely effect of various policy choices. This potential to inform does not mean that democratic and human rights considerations can or should be cast aside, hence there is no such thing as evidence based policy, only "evidence informed" policy. Failure to value the influence of forces other than science in forming health policy can have dangerous consequences for the accountability of politicians and scientists, and for the justification of policies that violate fundamental principles in a democratic society. We should refrain from casting so many issues as "science versus politics" because we scientists all have our own political commitments and values, and in that sense we stand on the same level as our fellow citizens rather than above them.

A retrospective economic evaluation of a female condom distribution and education program in Washington, DC was conducted. Standard methods of cost, threshold and cost-utility analysis were utilized as recommended by the U.S. Panel on cost-effectiveness in health and medicine. The overall cost of the program that distributed 200,000 female condoms and provided educational services was $414,186 (at a total gross cost per condom used during sex of $3.19, including educational services). The number of HIV infections that would have to be averted in order for the program to be cost-saving was 1.13 in the societal perspective and 1.50 in the public sector payor perspective. The cost-effectiveness threshold of HIV infections to be averted was 0.46. Overall, mathematical modeling analyses estimated that the intervention averted approximately 23 HIV infections (even with the uncertainty inherent in this estimate, this value appears to well exceed the necessary thresholds), and the intervention resulted in a substantial net cost savings.

Abstract
Background: Previous community-randomised trials of interventions to control sexually transmitted infections (STIs) have involved rural settings, were rarely multicomponent, and had varying results. We aimed to assess the effect of a multicomponent intervention on curable STIs in urban young adults and female sex workers (FSWs).

Methods: In this community-randomised trial, baseline STI screening was done between August, and November, 2002, in random household samples of young adults (aged 18-29 years) and in FSWs in Peruvian cities with more than 50 000 inhabitants. Geographically separate cities were selected, matched into pairs, and randomly allocated to intervention or control groups with an S-PLUS program. Follow-up surveys of random samples were done after 2 years and 3 years. The intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach to FSWs for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion for FSWs and the general population. Individuals in control cities received standard care. The composite primary endpoint was infection of young adults with Chlamydia trachomatis, Trichomonas vaginalis, or Neisseria gonorrhoeae, or syphilis seroreactivity. Laboratory workers and the data analyst were masked, but fieldworkers, the Peruvian study team, and participants in the outcome surveys were not. All analyses were done by intention to treat.

Findings: We did baseline surveys of 15 261 young adults in 24 Peruvian cities. Of those, 20 geographically separate cities were matched into pairs, in each of which one city was assigned to intervention and the other to standard of care. In the 2006 follow-up survey, data for the composite primary outcome were available for 12 930 young adults. We report a non-significant reduction in prevalence of STIs in young adults, adjusted for baseline prevalence, in intervention cities compared with control cities (relative risk 0.84, 95% CI 0.69-1.02; p=0.096). In subgroup analyses, significant reductions were noted in intervention cities in young adult women and FSWs.

Interpretation: Syndromic management of STIs, mobile-team outreach to FSWs, presumptive treatment for trichomoniasis in FSWs, and condom promotion might reduce the composite prevalence of any of the four curable STIs investigated in this trial.

The US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents has released updated Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Key additions and revisions to the guidelines include:

-New section on HIV and the older patient
-New table on cost of antiretroviral drugs
-Updated recommendations on initiation of antiretroviral therapy (ART) in treatment-naive individuals
-Expanded discussion of use of hormonal contraceptives in HIV-infected women
-Preliminary recommendations on co-administration of the newly approved hepatitis C virus (HCV) NS3/4A protease inhibitors (PIs) boceprevir and telaprevir
-Recommendations on "when to start" ART in HIV-infected individuals diagnosed with tuberculosis but not receiving ART
-Discussion of the role of effective ART in preventing HIV transmission

Dates: 7/19/2012 - 7/20/2012
Location: Washington, DC, United States
Sponsor: Virology Education
Contact: For more information, contact: E-mail: info@virology-education.com; Phone: +31 (0)30 230 7140; Fax: +31 (0)30 230 7148; or access the Web site at http://www.virology-education.com/.
Deadlines: Abstract submission, 11 May 2012; early registration, 1 April 2012
Objectives: To provide a forum for basic scientists, clinicians, virologists, epidemiologists, and public health officials to present and discuss the various aspects of HIV transmission.

Vanessa Marquez, a clinician at Fenway Community Health who has worked on several rectal microbicide trials and uses a number of strategies to rectally disarm her patients and others to great effect, will discuss rectal microbicide advocacy on this IRMA/AVAC teleconference - please join us for a really fun conversation. You may follow along with Vanessa's slides on the ReadyTalk web interface, or you may download her presentation in advance from the IRMA website here. The call is scheduled for 11am Eastern.