International response to the HIV/AIDS epidemic: planning for success.

More assertive political leadership in the global response to AIDS in both poor and rich countries culminated in June 2001 at the UN General Assembly Special Session on AIDS. Delegates made important commitments there, and endorsed a global strategy framework for shifting the dynamics of the epidemic by simultaneously reducing risk, vulnerability and impact. This points the way to achievable progress in the fight against HIV/AIDS. Evidence of success in tackling the spread of AIDS comes from diverse programme areas, including work with sex workers and clients, injecting drug users, and young people. It also comes from diverse countries, including India, the Russian Federation, Senegal, Thailand, the United Republic of Tanzania, and Zambia. Their common feature is the combination of focused approaches with attention to the societywide context within which risk occurs. Similarly, building synergies between prevention and care has underpinned success in Brazil and holds great potential for sub-Saharan Africa, where 90% reductions have been achieved in the prices at which antiretroviral drugs are available. Success also involves overcoming stigma, which undermines community action and blocks access to services. Work against stigma and discrimination has been effectively carried out in both health sector and occupational settings. Accompanying attention to the conditions for success against HIV/AIDS is global consensus on the need for additional resources. The detailed estimate of required AIDS spending in low- and middle-income countries is US$ 9.2 billion annually, compared to the $ 2 billion currently spent. Additional spending should be mobilized by the new global fund to fight AIDS, tuberculosis and malaria, but needs to be joined by additional government and private efforts within countries, including from debt relief. Commitment and capacity to scale up HIV prevention and care have never been stronger. The moment must be seized to prevent a global catastrophe.     

Q&A for physician practices: how to build long-term success with effective strategic planning sessions

As physician practices face stealthy marketplace competition, decreasing reimbursements, and increasing costs, it is crucial that they take a proactive approach toward strategic planning for their business. Merely accepting today's rocky business environment as the status quo and allowing it to dictate the direction of the practice can be a formula for failure. In fact, practices can and should rely on their colleagues and industry data for assistance and direction. As the saying goes, "There are no foolish questions." This article will address a few questions about strategic planning and how groups can implement an action plan to ensure success.     

What is the HACCP (hazard analysis critical control point) approach and how can it be applied to enteral tube feeding?

The HACCP (hazard analysis critical control point) concept is now widely applied in the food industry and provides a structured and critical approach to the identification and control of hazards that may affect food safety. It has shifted the emphasis for control from retrospective end-product testing to the effective control of raw materials and key processing operations.
This paper discusses how the HACCP approach can be applied to enteral feeding. This involves each unit assembling a multidisciplinary team of personnel involved in enteral feeding. This team will then carry out a detailed analysis of the process from selection of ingredients and feeding systems through to consumption of the feed by the patient by constructing a flow chart that relates specifically to each unit. They can then identify and assess the hazards associated with the handling of the product at each stage in the process. This will enable them to identify the points where control over an identified hazard can be achieved (critical control points, CCP) such as quality of ingredients, design of administration systems, preparation and distribution of the feeds and the procedures involved in the assembly and manipulation of the systems. Control and monitoring procedures can then be specified and implemented at relevant stages in the process. The major strengths of the HACCP procedure are that it entails a team effort from key personnel involved in the full range of activities associated with the product and each detailed analysis is specific to each unit's practices and resources and can be continually reviewed and modified in response to changing circumstances.     

AIDS: the epidemic no one wants to touch

In February 1990, the All India Institute of Medical Sciences issued a memorandum stating that no patients with acquired immunodeficiency syndrome (AIDS) would be accepted into its hospital until a special AIDS Unit was established. This position was taken in response to fears on the part of medical staff and physicians that they are at risk of contracting the AIDS virus through patient contact. However, such a stance is contrary to scientific evidence that AIDS transmission can be prevented in medical settings if appropriate precautions are taken and ignores the responsibility on the part of government health facilities to provide care to all patients in need. The basis of AIDS prevention in medical facilities is the avoidance of needle sticks in the handling of potentially contaminated, sharp instruments. Among the precautionary guidelines recommended by the objects with household bleach; the wearing of gloves, a gown, mask, and eye protection in all contact with potentially infected bodily fluids; provision of a special container for discarded needles; and the use of sealed bags for soiled linen and reusable supplies. There is no need to isolate patients with the AIDS virus unless they are too sick to maintain personal hygiene or have central nervous system involvement that is producing behavioral disorders.     

Market failure in the pharmaceutical industry and how it can be overcome: the CureShare mechanism

Allowing patients to take part in the initial investment for the development of cures for their illnesses can, under certain conditions, lead to the development of drugs that would have otherwise not been developed and to a dramatic welfare increase. We theoretically analyze these conditions. The suggested patient investment mechanism, which we call CureShare, does not involve any philanthropy or government subsidies. It is simply a way to overcome market failure. Based on empirical data, we estimate that applying this mechanism may save thousands of lives annually and may dramatically improve the quality of many others.     

Promoting palliative care to improve quality of life: how healthcare organizations can start and maintain effective programs

In recent years, many hospitals and healthcare organizations have begun to focus on palliative care for their patients with serious chronic, debilitating, or life-threatening illnesses. Today, about 950 hospitals provide palliative care to their patients-up from just a handful only 5 years ago. And the number is expected to quickly rise. But are these organizations' palliative care programs providing all the support and services they can to maintain quality care for their patients?     

Describing the HIV/AIDS epidemic: using HIV case data in addition to AIDS case reporting

PURPOSE: We examined the demographic and risk characteristics of persons with HIV using traditional AIDS case reporting and the more recent system that includes HIV diagnoses without AIDS. METHODS: Using data from 25 states with HIV reporting of HIV/AIDS cases diagnosed from 1994 through 2001, we calculated percentage distributions, annual diagnosis rates, and estimated annual percent change (EAPC) for persons with HIV (all HIV diagnoses with or without AIDS) and persons with AIDS. RESULTS: The age at diagnosis of persons with all stages of HIV tended to be younger than that of the subset of persons with AIDS. Annual diagnosis rates decreased more among AIDS cases (men: EAPC, - 9.76; 95% CI, - 12.00, - 7.45; women: EAPC, - 3.40; 95% CI - 5.72, - 1.02) than for persons with HIV (men: EAPC, - 6.14; 95% CI, - 7.66, - 4.60; women: EAPC, - 2.99; 95% CI, - 4.15, - 1.82), except among women and black non-Hispanics, for whom the difference in the decreases in rates for both disease groups were small. Injection drug use was a more common mode of exposure for women with AIDS than for women with HIV. CONCLUSIONS: The epidemiology of HIV differs for certain key population groups from that of AIDS.     

Interventions designed to increase adult fruit and vegetable intake can be effective: a systematic review of the literature

International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods > or = 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by approximately 0.1-1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.     

Shifting the burden: the private sector's response to the AIDS epidemic in Africa

As the economic burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organizations, and the burden is being systematically shifted away from the private sector. Common practices that transfer the burden to households and government include pre-employment screening, reductions in employee benefits, restructured employment contracts, outsourcing of low skilled jobs, selective retrenchments, and changes in production technologies. Between 1997 and 1999 more than two-thirds of large South African employers reduced the level of health care benefits or increased employee contributions. Most firms also have replaced defined-benefit retirement funds, which expose the firm to large annual costs but provide long-term support for families, with defined-contribution funds, which eliminate risks to the firm but provide little for families of younger workers who die of AIDS. Contracting out previously permanent jobs is also shielding firms from benefit and turnover costs, effectively shifting the responsibility to care for affected workers and their families to households, nongovernmental organizations, and the government. Many of these changes are responses to globalization that would have occurred in the absence of AIDS, but they are devastating for the households of employees with HIV/AIDS. We argue that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.     

Changing Swedish students' attitudes in relation to the AIDS epidemic

In the present study we have evaluated the knowledge, attitudes and intention to act in relation to HIV/AIDS related issues among Swedish students aged 15-18 years. An intervention group (n = 368) and a comparison group (n = 180) were followed for 2 years between 1989 and 1991. The teachers of the intervention group were obliged to specifically give a continuous and in-depth education while the comparison group received ordinary traditional education. We present the results from questionnaires given to all students before and after the study. There was a significant increase in knowledge of facts in the intervention group, and also changes in attitudes towards, for example, gay people, drug users and HIV infected individuals, in a desirable direction. In sex related issues there was also a desirable change in intention to act, but this was not seen in students' relation to alcohol. No significant changes at all in knowledge, attitudes or intention to act were seen in the comparison group. Our results show that it is indeed possible to influence students' attitudes and intention to act in HIV/AIDS related issues provided teachers start by defining the students' central conceptions and their relation to each other, and promote individual thinking and reflection.