United Nations system efforts to support the response to AIDS in China

In the last two years, we have seen a remarkable intensification in the response to AIDS in China. A number of organizations have joined and contributed to the efforts of the Chinese government in responding the AIDS epidemic in China. This article specifically describes the role of the United Nations in supporting and strengthening those responses.Achievements of the United Nations (UN) highlighted in the article include: strengthened leadership and political commitment to respond to AIDS; improved HIV/AIDS surveillance and information; expanded prevention efforts; improved treatment, care and support to people living with HIV and increased resources for AIDS programs. Additional roles of e., one national plan on AIDS; one national coordinating authority for AIDS; and one monitoring and evaluation system for AIDS. In addition, the UN system is expected to strengthen alignment and harmonization of activities of all international organizations and improved accountability and oversight. Remaining challenges identified include increasing awareness of AIDS and reducing stigma and discrimination; reducing vulnerability and risk behaviour among specific groups;providing improved treatment, care and support for people living with HIV; promoting stronger engagement by civil society, and; addressing the gender dimensions of AIDS.     

Women and AIDS: the ethics of exaggerated harm

This article examines the way in which some biomedical ethicists have constructed sexually transmitted AIDS as a significant threat to women's health. We demonstrate that the familiar claim that'women are the fastest growing group'— whether of HIV-infected or of AIDS patients — is misleading because it obscures the distinction between proportional rate of growth and absolute increase. Feminist ethicists have suggested that misogyny of a male dominated health care system has led to underreporting of women AIDS cases in order to support these feminists'claim of AIDS being a real threat to women's health. Given the apparent rarity of tertiary transmissions of AIDS, the assertion that most or even many women are at significant risk for AIDS seem wrong. Particularly disturbing in this campaign is the fact that the theme of'risky sex'has been extended all the way to lesbians, even though their risk to acquire AIDS sexually is non-existent to minuscule. We argue that actual harm is done to women by this exaggeration of their risk of contracting AIDS sexually. The scare has led to misappropriations of scarce health care funds. AIDS disproportionately affects women who inject drugs, and who suffer other diseases, poverty and malnutrition. It would have been better to concentrate health care efforts in this area instead of'educating'women not at risk for AIDS how to prevent the acquisition of this disease. Unjustifiable AIDS anxiety has been created in women and has resulted in millions of unnecessary HIV-tests, and many broken relationships. This anxiety has inevitably reduced the pleasure of having sex for many women. We reject the kind of'victim ideology'that lies at the heart of this strategy which has, unfortunately, been supported by a number of influential feminist ethicists.     

United Nations system efforts to support the response to AIDS in China

In the last two years, we have seen a remarkable intensification in the response to AIDS in China. A number of organizations have joined and contributed to the efforts of the Chinese government in responding the AIDS epidemic in China. This article specifically describes the role of the United Nations (UN) in supporting and strengthening those responses. Achievements of the United Nations highlighted in the article include: strengthened leadership and political commitment to respond to AIDS; improved HIV/AIDS surveillance and information; expanded prevention efforts; improved treatment, care and support to people living with HIV and increased resources for AIDS programs. Additional roles of the United Nations system in the near future include strengthening national leadership by supporting the 'three ones', i.e., one national plan on AIDS; one national coordinating authority for AIDS; and one monitoring and evaluation system for AIDS. In addition, the UN system is expected to strengthen alignment and harmonization of activities of all international organizations and improved accountability and oversight. Remaining challenges identified include increasing awareness of AIDS and reducing stigma and discrimination; reducing vulnerability and risk behaviour among specific groups; providing improved treatment, care and support for people living with HIV; promoting stronger engagement by civil society, and; addressing the gender dimensions of AIDS.     

Doctors' rights and patients' obligations

Marshall examines arguments for and against physicians breaching their duty of confidentiality to persons diagnosed with HIV or AIDS by notifying third parties such as sexual partners or general practitioners who give care unrelated to HIV or AIDS. The arguments presuppose that the confidentiality right is not absolute, but may give way under certain circumstances. A physician's obligations to the larger community, for instance, may outweigh the obligation to keep a diagnosis of AIDS or HIV confidential. Marshall also argues that physicians who incur risks by treating patients with AIDS or HIV have a right to knowledge that will help them protect themselves. A patient with AIDS or HIV may be obliged to reveal this fact to physicians when seeking care for other health problems, or to allow the diagnosing physican to do so. These arguments may have implications for the debate over testing patients for AIDS or HIV without consent.     

The World Health Organization's Global Strategy for the Prevention and Control of AIDS

The magnitude of the human immunodeficiency virus (HIV) pandemic and its broad impact have been seriously underestimated and underappreciated. The Special Programme on AIDS (acquired immunodeficiency syndrome) of the World Health Organization (WHO) was created on February 1, 1987, as the architect and keystone of the global AIDS plan. The Special Programme on AIDS has designed the global strategy, has raised sufficient funds to begin implementing the strategy and, for this effort, has marshalled the support of every nation in the world. AIDS affects both the developing and the industrialized worlds; therefore, every country will need a national AIDS program. This is vital not only for national interests but also because ultimately AIDS cannot be stopped in any one country unless it is stopped in all countries. National AIDS programs are being rapidly established throughout the world with the technical and financial support of WHO''s Special Programme on AIDS. At the global level, the Special Programme is responsible for strategic leadership, developing consensus, coordinating scientific research, exchanging information, assuring technical cooperation and mobilizing and coordinating resources. National AIDS committees have already been established in more than 150 countries and, by the end of 1988, the Special Programme will support every country in the world that requests collaboration.     

Funding policies for HIV and AIDS: time for change.

Funding for HIV and AIDS in England has been allocated to regions by a formula based on the number of cases of AIDS and HIV infection and on population size. Regions have distributed the resources directly to hospitals and community services. A survey of staff and managers in North East Thames region showed that funding arrangements have led to unsatisfactory development of services for HIV and AIDS. Firstly, because hospitals are funded according to current numbers of patients services are highly developed at the central London hospitals and underdeveloped in outer districts. Secondly, specialised community care teams have been established rather than integrating care for HIV and AIDS into generic primary care. Thirdly, the information on district of residence of infected patients is inaccurate, limiting allocation of funds according to population needs. Fourthly, prevention of infection has been given far less attention than treatment and care despite the lack of effective treatment. In future allocations for HIV and AIDS should be made to purchasers rather than directly to providers.     

Precautions and recommended attitudes for hospital personnel and the patient's environment

A transmissible agent especially a retrovirus (HTLV, LAV), is now widely considered in AIDS etiology. Similarities do exist between the epidemiology of AIDS and hepatitis B virus infections. Therefore, recommendations for preventing potential transmissions of AIDS are similar to those for preventing hepatitis B transmission. Nevertheless, the full blown disease called AIDS is probably one of the clinical expressions of the disease. Other clinical manifestations and healthy carriers should be eventually taken into consideration in respect of transmission. At the present time, there have been no documented cases of AIDS in medical care workers that can be to specific occupational exposures. In fact, transmissibility of AIDS seens very low.     

HIV+/AIDS related bioethical issues in Japan

Annual and cumulative incidences of HIV+ and AIDS in patients reported by the AIDS Surveillance Committee of the Ministry of Health and Welfare are cited to illustrate some characteristics in Japan: nearly 59% of either HIV+ or AIDS patients were infected through injection of blood products or by blood transfusion. A number of plaintiffs have sued the Japanese government and pharmaceutical companies since 1989, but no judicial decisions have yet been made. The incidence of HIV decreases for each of the following routes of infection: the second highest route of transmission being heterosexual, followed by bisexual and unconfirmed or unknown cases, and less frequently homosexual, drug use and lastly via vertical transmission. The most serious bioethical problems with HIV+ and AIDS patients in Japan is the social segregation of these patients. There are many emotional fears among the general public and medical personnel about AIDS because of their inadequate scientific knowledge of this disease. The Japan Hospital Association is doing The Stop AIDS Campaign and made several surveys. Japan has become increasingly aware of the importance of AIDS education and a great deal of effort is being made to enhance bioethical consideration.     

Five myths about AIDS that have misdirected research and treatment

A number of widely repeated and factually incorrect myths have pervaded the AIDS research literature, misdirecting research and treatment. Five of the most outstanding are: 1) that all risk groups develop AIDS at the same rate following HIV infection; 2) that there are no true seroreversions following HIV infection; 3) that antibody is protective against HIV infection; 4) that the only way to treat AIDS effectively is through retroviral therapies; and 5) that since HIV is so highly correlated with AIDS incidence, it must be the sole necessary and sufficient cause of AIDS. A huge body of research, reviewed in this paper, demonstrates the falsity of these myths. 1) The average number of years between HIV infection and AIDS is greater than 20 years for mild hemophiliacs, 14 years for transfussion severe hemophiliacs, 10 years for old severe hemophiliacs, 10 years for homosexual men, 6 years for transfusion patients of all ages, 2 years for transplant patients, and 6 months for perinatally infected infants. These differences can only be explained in terms of risk-group associated cofactors. 2) Seroreversions are common. Between 10 and 20 percent of HIV-seronegative people in high risk groups have T-cell immunity to HIV, and may have had one or more verified positive HIV antibody tests in the past. 3) Antibody, far from being protective against HIV, appears to be highly diagnostic of loss of immune regulation of HIV, and some evidence of antibody-enhancement of infection exists. 4) Non-retroviral treatments of HIV infection, including safer sex practices, elimination of drug use, high nutrient diets, and limited reexposure to HIV and its cofactors have proven to be effective means of preventing or delaying onset of AIDS. 5) Many immunosuppressive factors, including drug use, multiple concurrent infections, and exposure to alloantigens, are as highly correlated with AIDS risk groups as HIV. These data are more consistent with AIDS being a multifactorial or synergistic disease than a monofactorial one.     

Distribution of the level of antibody to AIDS-associated virus (LAV) in sera from AIDS or AIDS related complex and Japanese hemophiliacs infected with AIDS-associated virus

The level of antibody to AIDS-associated virus (LAV) in sera from patients with AIDS or AIDS related diseases (AIDS related complex; ARC) and Japanese hemophiliacs was studied using indirect immunofluorescence. Titer of anti-LAV antibody in sera from 89 patients with AIDS or ARC ranged between 10 and 40,960 (median: 1,280) and that of 83 Japanese hemophiliacs ranged from 20 to 20,480 (median: 640). The distribution of the level of anti-LAV antibody in hemophiliacs was similar to that of patients with AIDS or ARC, and no correlation between the titer of antibody and the presence of symptoms of AIDS was observed. Our results suggested that hemophiliacs in Japan might have been infected with live LAV rather than been immunized with inactivated LAV by injection of factor VIII or IX concentrate, and more hemophiliacs in Japan might show symptoms of AIDS in the future as in the United States.     

The importance of nonhuman primate research in the battle against AIDS: A historical perspective

Retroviruses have been the common foe in two recent “wars,” first against cancer, then against AIDS. Although neither war is close to over, some battles have been won, thanks in part to research using nonhuman primates. As useful as these animals were in studying retroviruses and cancer, their contribution to AIDS research is already far greater. This paper will briefly review the major contribution of nonhuman primates and their retroviruses to research on cancer and AIDS.     

AIDS in the infant

Recently, we and others have encountered a group of infants who developed AIDS. They were born from parents who belonged to identified risk factors for AIDS. The clinical and immunologic features were described. The existence of a pediatric form of AIDS transmitted other than by transfusion suggests the possibility of transplacental perinatal or postnatal transmission.     

Spontaneous cytotoxicity and tumor necrosis factor production by peripheral blood monocytes from AIDS patients

Peripheral blood monocytes (PBM) from AIDS patients have exhibited defects in some but not all of the immune functions yet tested. This study has examined the capacity of AIDS PBM to lyse tumor target cells as well as their ability to secrete TNF. Untreated PBM from AIDS patients were significantly cytotoxic to U937 target cells and responded to IFN-gamma pretreatment with augmented cytotoxicity. Both the spontaneous and IFN-gamma-stimulated cytotoxic activity was significantly (p less than 0.01) higher than that observed with normal PBM. The cytotoxic activity depended on the E:T ratio used and was higher in AIDS PBM at all ratios tested (10:1 to 40:1). Because TNF has been implicated in macrophage cell-mediated cytotoxicity, we examined whether the elevated cytotoxic activity of AIDS PBM was associated with an increase in TNF production. Supernatants from PBM cultured overnight with or without IFN-gamma were tested in a bioassay measuring cytotoxicity against U937 target cells as well as in an RIA specific for TNF. Supernatants derived from either unstimulated or IFN-gamma-treated AIDS PBM exhibited significantly higher levels of cytotoxicity than supernatants from normal macrophages. Both normal and AIDS PBM produced higher levels of cytotoxic factors in response to IFN-gamma. As determined by the RIA, AIDS PBM spontaneously released high levels of TNF whereas little TNF was produced by normal PBM. Treatment with IFN-gamma augmented the level of TNF production in both AIDS and normal PBM. These results demonstrate that PBM from AIDS patients have undergone in vivo activation as manifested by both cytotoxicity against tumor target cells and production of TNF. Target cell lysis by both AIDS PBM and their supernatants was inhibited by monoclonal anti-rTNF, suggesting that the increase in PBM cell-mediated cytotoxicity was caused by an increase in TNF production. The significance of these findings in the pathogenesis of the disease is discussed.     

IS IT ETHICAL TO STUDY WHAT OUGHT NOT TO HAPPEN?1

In the Democratic Republic of Congo, only an estimated 2% of all AIDS patients have access to treatment. As AIDS treatment access is scaled-up in the coming years, difficult rationing decisions will have to be made concerning who will come to gain access to this scarce medical resource. This article focuses on the position, expressed by representatives of Médecins sans Frontières (MSF), that the practice of AIDS treatment access rationing is fundamentally unethical because it conflicts with the ideal of universal treatment access and the human right to health. The conclusion is that MSF's position lacks coherence, has negative practical implications, and is unfair to governments struggling to increase patient's access to AIDS treatment in unfavorable circumstances.     

Course of HIV-I infection in a cohort of homosexual and bisexual men: an 11 year follow up study.

OBJECTIVE--To characterise the natural history of sexually transmitted HIV-I infection in homosexual and bisexual men. DESIGN--Cohort study. SETTING--San Francisco municipal sexually transmitted disease clinic. PATIENTS--Cohort included 6705 homosexual and bisexual men originally recruited from 1978 to 1980 for studies of sexually transmitted hepatitis B. This analysis is of 489 cohort members who were either HIV-I seropositive on entry into the cohort (n = 312) or seroconverted during the study period and had less than or equal to 24 months between the dates of their last seronegative and first seropositive specimens (n = 177). A subset of 442 of these men was examined in 1988 or 1989 or had been reported to have developed AIDS. MAIN OUTCOME MEASURES--Development of clinical signs and symptoms of HIV-I infection, including AIDS, AIDS related complex, asymptomatic generalised lymphadenopathy, and no signs or symptoms of infection. MEASUREMENTS AND MAIN RESULTS--Of the 422 men examined in 1988 or 1989 or reported as having AIDS, 341 had been infected from 1977 to 1980; 49% (167) of these men had died of AIDS, 10% (34) were alive with AIDS, 19% (65) had AIDS related complex, 3% (10) had asymptomatic generalised lymphadenopathy, and 19% (34) had no clinical signs or symptoms of HIV-I infection. Cumulative risk of AIDS by duration of HIV-I infection was analysed for all 489 men by the Kaplan-Meier method. Of these 489 men, 226 (46%) had been diagnosed as having AIDS. We estimated that 13% of cohort members will have developed AIDS within five years of seroconversion, 51% within 10 years, and 54% within 11.1 years. CONCLUSION--Our analysis confirming the importance of duration of infection to clinical state and the high risk of AIDS after infection underscores the importance of continuing efforts both to prevent transmission of HIV-I and to develop further treatments to slow or stall the progression of HIV-I infection to AIDS.     

亚洲各国艾滋病疫苗简介

获得性免疫缺陷综合征(acquired immunodeficiencysy ndrome,AIDS),即"艾滋病",是一种致死率极高的全球传染性疾病,尚无有效的治愈方法。目前,亚洲已成为世界第二大艾滋病高发区。对经济并不发达的亚洲地区来说,研发艾滋病疫苗,对于预防人类免疫缺陷病毒(human immunodeficiency virus,HIV),即"艾滋病病毒"的传播具有重要的战略意义。本文对中国、泰国、印度、日本和澳大利亚的艾滋病疫苗研发和临床试验进行了分析和总结,并分析了亚洲开发艾滋病疫苗的前景及应对策略。     

HIV +/AIDS RELATED BIOETHICAL ISSUES IN JAPAN

Annual and cumulative incidences of HIV + and AIDS in patients reported by the AIDS Surveillance Committee of the Ministry of Health and Welfare are cited to illustrate some characteristics in Japan: nearly 59% of either HIV + or AIDS patients were infected through injection of blood products or by blood transfusion. A number of plaintiffs have sued the Japanese government and pharmaceutical companies since 1989, but no judicial decisions have yet been made. The incidence of HIV decreases for each of the following routes of infection: the second highest route of transmission being heterosexual, followed by bisexual and unconfirmed or unknown cases, and less frequently homosexual, drug use and lastly via vertical transmission. The most serious bioethical problems with HIV + and AIDs patients in Japan is the social segregation of these patients. There are many emotional fears among the general public and medical personnel about AIDS because of their inadequate scientific knowledge of this disease. The Japan Hospital Association is doing The Stop AIDS Campaign and made several surveys. Japan has become increasingly aware of the importance of AIDS education and a great deal of effort is being made to enhance bioethical considerations.     

Prevalence of HIV antigens in cerebrospinal fluid and in serum of patients with both asymptomatic and symptomatic HIV infection]

Prevalence of HIV-Ag in both serum and CSF has been determined in 19 HIV infected patients, including 7 patients without any symptoms or only generalized lymphadenopathy, 5 patients with ARC and 7 patients with AIDS. The results have been correlated with clinically evident neurological disorders. HIV-Ag have been detected in 9 out of 12 patients with ARC (AIDS Related Complex) and AIDS. In 8 of them neurological disorders have been present. Out of the remaining 7 patients in only one HIV-Ag has been detected in CSF (p < 025). No correlation between the presence of HIV antigen in CSF and serum has been noted.     

Supporters and survivors: the people without AIDS.

Over the past 10 years the AIDS crisis has produced a large volume of writing. Much of this is documentary. Dozens of studies of AIDS from various clinical and political perspectives have been complemented by just as many published diaries, autobiographies, novels, plays, and poems. A few of these works have risen to the surface not only as extraordinarily valuable testimonies to the changes AIDS has wrought in individual and collective life but also as first-rate literary works, worth reading because beyond their immediate purposes they articulate with extraordinary lucidity and compassion some deep truths about the human--and the modern--condition. Paul Monette's Borrowed Time is among the most distinctive of those. It speaks not only for the community of people with AIDS and those who support them but for a generation.