Overview of Studies – Final

Overview of studies

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Carmen Antiretroviral treatment for Addiction ‗06 8 X Aceijas, Edna injecting drug users in Oppenheimer, developing and transitional Gerry Stimson, countries 1 year before the Richard end of the ‗Treating 3 million Ashcroft, Srdan by 2005. Making it happen. Matic, The WHO strategy‘ (‗3by5‘) 1 Matthew Hickman African The African Evaluation Evaluation & ‗02 11 X Evaluation Guidelines: 2002. A checklist Program networks to assist in planning Planning (diverse) & evaluations, negotiating clear others contracts, reviewing progress and ensuring adequate completion of an evaluation 2 Martha AIDS and public policy: the Health Policy ‗03 24 X X Ainsworth, lessons and challenges of Chris Beyrer, ‗success‘ in Thailand 3 Agnes Soucat

Martha Is it really working? CGD - ‗06 57 = X X Ainsworth, Ruth HIV/AIDS, Global Initiatives, Transcript 20 Levine, Michele and the pressing challenge of prepared from a nor Orza, Cyril evaluation 4 tape recording mal Pervilhac p. Alban A, Review of cost-effectiveness ADB & UNAIDS ´07 X Manuel C, of Injecting Drug User Hjorth Hansen interventions to prevent HIV D, Nielsen S, in Asia. 5 Fatima M. Anita Alban, Hiv/aids‘ udbredelse og Ugeskrift for ‗06 5 X Nina Bjerglund indflydelse på andre Læger Andersen sundheds-relaterede 2015- mål6 Ian Askew, The Contribution of Sexual Reproductive ‗03 22 X X Marge Berer and Reproductive Health Health Matters Services to the Fight against HIV/AIDS: A Review 7 Rebecca Modelling the Impact of PLOS Medicine ‗05 12 X Baggaley, Antiretroviral Use Geoff Garnett, in Resource-Poor Settings 8 Neil Ferguson Robert Bailey, Male circumcision for HIV Lancet ‗07 14 X Stephen prevention in young men in Moses, Corette Kisumu, Kenya: a Parker, randomised controlled trial 9 Kawango Agot,

1 Includes cross-cutting issues, e.g. cost-effectiveness

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Ian Maclean, John Krieger, Carolyn Williams, Richard Campbell, Jeckoniah Ndinya-Achola Bateganya MH, Home-based HIV voluntary Cochrane ‗07 32 X Abdulwa-dud counseling and testing in Database of OA, Kiene SM developing countries Systematic (Review) 10 Review DrImelda Vulnerability to malaria, Lancet ‗04 10 X Bates, Caroline tuberculosis, and HIV/AIDS Infectious Fenton, Janet infection and disease. Part 1: Diseases Gruber, David determinants operating at Lalloo, individual and household Antonieta level 11 Medina Lara, Bertel Squire, Sally Theobald, Vulnerability to malaria, Lancet ‗04 7 X Rachael tuberculosis, and HIV/AIDS Infectious Thomson, infection and disease. Part II: Diseases Rachel Tolhurst determinants operating at environmental and institutional level 12 Sara Bennett, Scaling up HIV/AIDS Lancet ‗06 4 X Ties Boerma, evaluation 13 Ruairí Brugha Marge Berer HIV/AIDS, sexual and Health Policy & ‗04 9 X reproductive health: Planning intersections and implications for national programmes 14 Michael A trickle or a Flood: Center for ‗07 25 X Bernstein, Myra Commitments and Global Develop- sessions Disbursement for HIV/AIDS ment/ from the Global Fund, HIV/AIDS PEPFAR, and the World Monitor Bank‘s Multi-Country AIDS Program (MAP) 15 Jane T. Systematic review of the Health ‗06 31 X Bertrand, Kevin effectiveness of mass Education O‘Reilly, Julie communication programs to Research – Denison, change HIV/AIDS-related Theory & Rebecca behaviors in developing Practice Anhang, countries 16 Michael Sweat David Bloom, A Global Review of the World Economic ‗06 36 X Lakshmi Reddy Business Forum Bloom, David Response to HIV/AIDS 2005- Steven and 2006 17

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Mark Weston Omotayo Bolu, Approaches for scaling up American ‗07 6 X Virginia Allread, human immunodeficiency Journal of Tracy Creek, virus testing and counseling Obstetrics & Elizabeth in prevention of mother-to- Gynecology Stringer, Fatu child human Forna, Marc immunodeficiency virus Bulterys, transmission settings in Nathan Shaffer resource-limited countries 18 Ruarí Brugha et GLOBAL FUND TRACKING report ‗05 26 X al STUDY Mozambique Tanzania Uganda Zambia COUNTRY SUMMARIES and CONCLUSIONS 19 Ruarí Brugha The Global Fund at three Tropical ‗05 4 X years – flying in crowded Medicine & air space 20 International Health Ruarí Brugha Evaluation of HIV BMJ ‗07 2 X Programmes 21 Rebecca Changes in sexual behavior Aids ‗06 8 X Bunnell, John and risk Paul Ekwaru, of HIV transmission after Peter Solberg, antiretroviral Nafuna Wamai, therapy and prevention Winnie interventions in Bikaako-Kajura, rural Uganda 22 Willy Were, Alex Coutinho, Cheryl Liechty, Elizabeth Madraa, George Rutherford, Jonathan Mermin Susan Cleary, The cost-effectiveness of BioMed Central ‗06 14 X Di McIntyre. Antiretroviral treatment in – Open Access Andrew Boulle Khayelitsha, South Africa – a primary data analysis 23 Elizabeth Uptake of Workplace HIV PLOS Medicine ‗06 8 X Corbett, Ethel Counselling Dauya, Ronnie and Testing: A Cluster- Matambo, Yin Randomised Trial in Bun Cheung, Zimbabwe 24 Beauty Makamure, Mary Bassett, Steven Chandiwana, Shungu

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Munyati, Peter Mason, Anthony Butterworth, Peter Godfrey- Faussett, Richard J. Hayes Tracy Creek, Infant human American ‗07 7 X Gayle immunodeficiency virus Journal of Sherman, John diagnosis in resource-limited Obstetrics and Nkenga-song, settings: issues, Gynecology Lydia Lu, technologies, and country Thomas experiences 25 Finkbeiner, Mary Fowler, Emilia Rivadenei-ra, Nathan Shaffer Andrew Cost-effectiveness of Lancet ‗02 8 X Creese, HIV/AIDS interventions in Katherine Africa: a systematic review of Floyd, Anita the evidence 26 Alban, Lorna Guinness Wim Van Health System Strengthening Reproductive ‗06 3 X Damme, Guy and Scaling Up Health Matters Kegels Antiretroviral Therapy: The Need for Context-Specific Delivery Models: Comment on Schneider et al 27 Danida Review of the Danish report ‗04 25 X Support to HIV/AIDS-related activities in programme countries Country Case Studies Uganda 28 Annette David, The Prevention and Control Journal of Urban ‗07 10 X Susan of HIV/AIDS, TB and Vector- Health: Bulletin Mercado, borne Diseases in Informal of the New York Daniel Becker, Settlements: Challenges, Academy of Katia Edmundo, Opportunities and Insights 29 Medicine Frederick Mugisha SouleymanDiab Determinants of adherence to Aids ‗07 5 X até, Michel highly active antiretroviral Alary, therapy among HIV-1- Constance infected patients in Côte Kanga Koffi d‘Ivoire 30 Nel Druce, Seizing the Big Missed Reproductive ‗07 11 X Anne Nolan Opportunity: Linking HIV and Health Matters Maternity Care Services in

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Sub-Saharan Africa 31 Chistopher The Science of Microbicides: A Report by the ‗05 80 X Elias, Chairman Accelerating Development 32 Science Working Group of the Microbicide Initiative funded by The Rockefeller Foundation H. Elsey, R. Mainstreaming HIV/AIDS in AIDS Care ‗05 10 X Tolhurst, S. development sectors: Have Theobald we learnt the lessons from gender mainstreaming? 33 Roger England Are we spending too BMJ ‗07 1 X much on HIV? 34 Roger England HIV antiretroviral therapy: DfID Health 06 13 X can franchising expand Resource coverage? 35 Centre Henrik Friis Micronutrient interventions Tropical ‗06 8 X and HIV infection: a review Medicine & of current evidence 36 International Health Melanie School-based HIV prevention Social Science & ‗04 14 X Gallant, programmes for African youth Medicine Eleanor 37 Maticka- Tyndale Aisha Gilliam, Building evaluation capacity Evaluation & ‗03 9 X Tracey for HIV prevention programs Program Barrington, 38 Planning David Davis, Romel Lacson, Gary Uhl,Ursula Phoenix Global HIV Global Mobilization for HIV report ‗02 26 X Prevention Prevention - Working Group a blueprint for action 39 Global HIV New approaches to HIV report ‗06 32 X Prevention prevention 40 Working Group Ronald Gray, Probability of HIV-1 Lancet ‗01 5 X Maria Wawer, transmission per coital act in Ron Brook- monogamous, meyer, Nelson heterosexual, HIV-1- Sewankambo, discordant couples in Rakai, David Uganda 41 Serwadda, Fred Wabwire- Mangen, Tom Lutalo, Xianbin Li,

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Thomas van Cott, Thomas Quinn, the Rakai Project Team Ronald Gray, Male circumcision for HIV Lancet ‗07 10 X Godfrey Kigozi, prevention in men in Rakai, David Uganda: a randomised trial 42 Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence Moulton, Mohammad Chaudhary, Michael Chen, Nelson Sewankambo, Fred Wabwire- Mangen, Melanie Bacon, Carolyn Williams, Pius Opendi, Steven Reynolds, Oliver Laeyen- decker, Thomas Quinn, Maria Wawer Lorna Guinnes, 10 best resources in . . . cost Health Policy & ‗04 4 X Ruth Levine, analysis for HIV/AIDS Planning Marcia Weaver programmes in low and middle income countries 43 Handford CD, Setting and organization of Cochrane X X Tynan AM, care for persons living with Database of Rackal JM, HIV/AIDS (Review) 44 Systematic Glazier RH Review Kari Hartwig, AIDS and ―shared Social Science & ‗05 11 X Eugenia Eng, sovereignty‖ in Tanzania from Medicine Mark Daniel, 1987 to 2000: a case study 45 Thomas Ricketts, Sandra Quinn Ian Hastings, Continued correspondence Aids ‗07 1 X David, Lalloo, ‗Will ART rollout in Africa Saye Khoo drive an epidemic of drug- resistant HIV?‘ 46 Norman Hearst, Condom Promotion for AIDS Studies in ‗04 9 X

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Sanny Chen Prevention in the Developing Family Planning World: Is It Working? 47 Lisa Estimating health workforce Human ‗06 16 X Hirschhorn, needs for antiretroviral Resources for Lulu Oguda, therapy in resource-limited Health Andrew Fullem, settings 48 Norbert Dreesch, Paul Wilson Oliver Achieving the global goals on In: UNAIDS ‗06 19 X Hoffmann, HIV Inter-agency Tania Boler, among young people most at Task Team on Bruce Dick risk in Young People: (document developing countries: young Preventing under the sex HIV/AIDS UNAIDS workers, injecting drug users In Young People Interagency and - A Systematic Task Team men who have sex with men Review of the report) 49 Evidence from Developing Countries. WHO Technical Report Series Daniel Hogan, Achieving the millennium BMJ ‗05 8 X Rob Baltussen, development goals for health Chika Hayashi, Cost effectiveness analysis of Jeremy Lauer, strategies to combat Joshua HIV/AIDS in developing Salomon countries 50 Cheng-cheng Joint Modelling of Biometrics ‗07 9 X Hu, Victor De Progression of HIV Gruttola Resistance Mutations Measured with Uncertainty and Failure Time Data 51 Louise C. Ivers, Efficacy of Antiretroviral Clinical ‗05 8 X David Kendrick, Therapy Programs in Infectious and Karen Resource-Poor Settings: A Diseases Doucette Meta-analysis of the Published Literature 52 Kalichman&al + Male circumcision in HIV Lancet ‘07 1 X Brewer&al Prevention 53 C.Kennedy, K. The impact of HIV treatment AIDS Care ‗07 14 X O'Reilly, A. on risk behaviour in Medley, M. developing countries: A Sweat systematic review 54 James The Economic Returns To HNP Discussion ´05 X Knowles, Jere Investing In Youth In Paper, World Behrman Developing Countries: Bank A Review of the Literature 55 Jens Kovsted Scaling Up AIDS Treatment Develop-ment ‗05 18 X in Developing Policy Review Countries: A Review of

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Current and Future Arguments 56 Christian Effectiveness and safety of a Lancet ‗04 6 X Laurent, generic fixed-dose Charles combination of nevirapine, Kouanfack, stavudine, and lamivudine in Sinata Koulla- HIV-1-infected adults in Shiro, Nathalie Cameroon: open-label Nkoué, Anke multicentre trial 57 Bourgeois, Alexandra Calmy, Bernadette Lactuock, Viviane Nzeusseu, Rose Mougnutou, Gilles Peytavin, Florian Liégeois, Eric Nerrienet, Michèle Tardy, Martine Peeters, Isabelle Andrieux- Meyer, Léopold Zekeng, Michel Kazatch-kine, Eitel Mpoudi- Ngolé, Eric Delaporte Paul de Lay, Are we spending too much BMJ ‗07 1 X Robert on HIV? 58 Greener, Jose Izazola Chunling Lu, Absorptive capacity and Lancet ‗06 6 X Catherine disbursements by the Global Michaud, Kashif Fund Khan, to Fight AIDS, Tuberculosis Christopher and Malaria: analysis of grant Murray implementation 59 Chewe Luo, Global Progress in PMTCT Reproductive ‗07 10 X X Priscilla and Paediatric HIV Care and Health Matters Akwara, Ngashi Treatment in Low- and Ngongo, Middle-Income Countries in Patricia 2004–2005 60 Doughty, Robert Gass, Rene Ekpini, Siobhan Crowley, Chika

Author Title Journal Year Pages Prevention Curative Palliative Mitigation Cooperation Evaluation

Hayashi Landis Priorities in Global Population & ‗05 19 X MacKellar Assistance for Health, Development AIDS, and Population 61 Review Magnussen, Interventions to prevent International ‗04 20 X Ehiri, Ejere, HIV/AIDS among Journal of Jolly adolescents in Adolescent less developed countries: are Health they effective? 62 Mahajan, An overview of HIV/AIDS AIDS ‗07 9 X Anish; Colvin, workplace policies and Mark; programmes in southern Rudatsikira, Africa Jean-Baptiste; 63 Ettl, David Charles HIV Pharmacotherapy Pharma- ‗07 7 X Maponga, Qing Issues, Challenges, and cotherapy in Ma, Judianne Priorities in sub-Saharan Slish, sub-Saharan African Africa Gene Morse Countries 64 Elliot Marseille, Assessing the Efficiency of HSR: Health ‗04 25 X Lalit Dandona, HIV Services Joseph Saba, Prevention around the World: Research Coline Methods McConnel, of the PANCEA Project 65 Brandi Rollins, Paul Gaist, Mattias Lundberg, Mead Over, Stefano Bertozzi, James Kahn Neddy Rita Mass orphanhood in the era BMJ ‗02 1 X Matshalaga, of HIV/AIDS 66 Greg Powell Sheena McCor- Microbicides in HIV BMJ ‗01 5 X mack, Richard prevention 67 Hayes, Charles Lacey, Anne Johnson Andrew HIV Vaccines 68 Annual Review ‗06 28? X McMichael of Immunology Jonathan Developing an evidence- Tropical ‗05 10 X Mermin, based, preventive care Medicine & Rebecca package for persons with HIV International Bunnell, John in Africa 69 Health Lule, Alex Opio, Amanda Gibbons, Mark Dybul, Jonathan

Kaplan Anne Mills, Challenge Paper on Copenha-gen ‗04 11 X Sam Shillcutt Communicable Diseases – Consensus Ch.4 control of HIV/AIDS 70 Challenge Paper Panda S, Needle syringe acquisition Subst Use ‗06 X Sharma M and HIV prevention among Misuse injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia. Mahesh Patel A meta-evaluation, or quality Evaluation & ‗02 3 X assessment, of the Program evaluations in this issue, Planning based on the African Evaluation Guidelines: 2002 71 Peter Piliero, Simplified Regimens for Journal of the ‗03 8 X Joseph Treating HIV Infection and American Colagreco AIDS 72 academy of nurse Practitioners Petersen, Assessing HIV resistance in Pan American ‗06 11 X Maya; Boily, developing countries: Brazil Journal of Public Marie- as a case study 73 Health Claude; Bastos, Francisco Peter Poore The Global Fund to fight Health Policy & ‗04 2 X Aids, Tuberculosis and Planning Malaria (GFATM) 74 Steven Radelet, Global Fund grant Lancet ‗07 18 X Bilal Siddiqi programmes: an analysis of evaluation scores 75 Richard Monitoring and evaluation of BMJ ‗07 5 X Reithinger,Kare programmes to prevent n mother to child transmission Megazzini,Step of HIV in Africa 76 hen Durako, Robert Harris, Sten Vermund Lisa Ann Better (RED)™ than Dead: DIIS Working ‗06 26 X Richey, Stefano ‗Brand Aid‘, Celebrities and Paper 2006/26 Ponte the New Frontier of Development Assistance 77 Laetitia Rispel, Education sector responses The ‗06 81 X Lebogang to HIV and AIDS: Learning Commonwealth Letlape, Carol from good practices in Africa Secretariat & Metcalf 78 ADEA Alana Government–NGO Evaluation & ‗07 ? X X Rosenber, Kari collaboration and Program Hartwig, sustainability of orphans and Planning Michael Merson vulnerable children projects in southern Africa 79 Rosen M, Fox Patient Retention in PLoS Medicine ‗07 X S & Gill C Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review 80 Steven Russell, Coming back from the dead: Health Policy & ‗07 4 X X Janet Seeley, living with HIV as a chronic Planning

Enoch Ezati, condition in rural Africa 81 Nafuna Wamai, Willy Were, Rebecca Bunnell Joshua Integrating HIV Prevention PLOS Medicine ‗05 7 X X Salomon, and Treatment: From Daniel Hogan, Slogans to Impact 82 John Stover, Karen Stanecki, Neff Walker, Peter Ghys, Bernhard Schwartländer Sangani P, Population-based Cochrane ‗01 ? Rutherford G, interventions for reducing Database of Wilkinson D. sexually transmitted Systematic infections, including HIV Review infection 83 George Transmission of HIV-1 Lancet ‗04 6 X Schmid, Anne infection in sub-Saharan Buvé, Peter Africa and effect of Mugyenyi, elimination of unsafe Geoff Garnett, injections 84 Richard J Hayes, Brian Williams, Jesus Calleja, Kevin De Cock, James Whitworth, Saidi Kapiga, Peter Ghys, Catherine Hankins, Basia Zaba, Robert Heimer, Ties Boerma Helen Health Systems and Access Reproducti-ve ‗06 12 X Schneider, to Antiretroviral Drugs for HIV Health Matters Duane Blaauw, in Southern Africa: Service Lucy Gilson, Delivery and Nzapfuru‘ Human Resources Chabikuli, Jane Challenges 85 Goudgee Whitney Schott, Effects of the Abt Associates 05 42 X Kate Stillman, Global Fund on report for Sara Bennett Reproductive PHRplus Health in Ethiopia and (USAID) Malawi: Baseline Findings 86 Alexander Global Fund – World Bank Report for ‗06 60 – X Shakow HIV/AIDS Programs GFATM & WB ExS Comparative Advantage um: Study 87 10 N Siegfried, M HIV and male circumcision— Lancet ‗05 7 X Muller, J a systematic review with Infectious Deeks, J assessment of the quality of Diseases Volmink, , M studies 88 (Cochrane Egger, N Low, Review) S Walker, P

Williamson Kate Stillman, System-wide Effects of the Report by Abt ‗05 50 X Sara Bennett Global Fund: Associates for Interim Findings from Three PHRplus Country studies 89 (USAID) N. Suksom- Systematic review of the Journal of ‗07 19 X boon, N. efficacy of antiretroviral Clinical Poolsup, S. therapies for reducing the risk Pharmacy and Ketaim of mother-to-child Therapeutics transmission of HIV infection 90 Darrell HS Tan, Global plagues and the BMC ‗03 9 X Ross EG Global Fund: Challenges in International Upshur, Nathan the fight against HIV, TB and Health and Ford malaria 91 Human Rights Fern Terris- The Costs of Treating Sexually ‗06 14 X Prestholt, Curable Sexually Transmitted Transmitted Seema Vyas, Infections in Diseases Lilani Low- and Middle-Income Kumarana- Countries: A Systematic yake, Philippe Review 92 Mayaud, Charlotte Watts Harsha The Economic Impact of Economic 49 X Thirumur-thy, AIDS Treatment: Growth Center, Joshua Graff Labor Supply in Western Yale University, Zivin, Kenya 93 Center Markus Discussion Goldstein Paper no. 947

UNAIDS, Women and HIV/AIDS: report ‗04 64 X UNFPA, Confronting the Crisis 94 UNIFEM Anna Vassall, Estimating the resource Health Policy ‗06 14 X Phil Comper- needs of scaling-up nolle HIV/AIDS and tuberculosis interventions in sub-Saharan Africa: A systematic review for national policy makers and planners 95 Damien de Discordant couples World Bank ‗06 27 X Walque HIV infection among couples Policy Research in Burkina Faso, Cameroon, Working Paper Ghana, Kenya, and Tanzania 3956 96 Damien de Who Gets AIDS and How? World Bank ‗06 51 X Walque The determinants of HIV Policy Research infection and sexual Working Paper behaviors in 3844 Burkina Faso, Cameroon, Ghana, Kenya and Tanzania 97 Damian Walker Cost and cost-effectiveness Health Policy & ‗03 13 X of HIV/AIDS prevention Planning strategies in developing countries: is there an evidence base? 98 Weller SC, Condom effectiveness in Cochrane ‗02 20 X Davis-Beaty K reducing heterosexual HIV Database of transmission (Review)99 Systematic

Reviews WHO-UNAIDS- Position Statement Position ‗04 3 X UNFPA On Condoms and HIV Statement Prevention 100 WHO-UNAIDS Roundtable: Male Reproductive ‗07 3 X Circumcision for HIV Health Matters Prevention: Research Implications for Policy and Programming WHO/UNAIDS Technical Consultation 6–8 March 2007 Conclusions and Recommendations (Excerpts) 101 Wools- Extending HIV care in Current ‘06 ? X Kaloustian K, resource-limited settings. 102 HIV/AIDS Kimaiyo S. Reports

Heather Zar, Effect of isoniazid prophylaxis BMJ ‗06 7 X Mark Cotton, on mortality and incidence of Stanzi Strauss, tuberculosis in children with Janine HIV: randomised controlled Karpakis, trial 103 Gregory Hussey, Simon Schaaf, Helena Rabie, Carl Lombard

Abstracts, Conclusions etc.:

1 Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the ‗Treating 3 million by 2005. Making it happen. The WHO strategy‘ (‗3by5‘). ABSTRACT Objective: To describe and estimate the availability of antiretroviral treatment (ART) to injecting drug users (IDUs) in developing and transitional countries. Methods: Literature review of grey and published literature and key informants‘ communications on the estimated number of current/former injecting drug users (IDUs) receiving ART and the proportion of human immunodeficiency virus (HIV) attributed to injecting drug use (IDU), the number of people in ART and in need of ART, the number of people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLWHA) and the main source of ART. Results: Data on former/current IDUs on ART were available from 50 countries (in 19 countries nil IDUs in treatment) suggesting that 34 000 IDUs were receiving ART by the end of 2004, of whom 30 000 were in Brazil. In these 50 countries IDUs represent 15% of the people in ART. In Eastern European and Central Asia IDU are associated with > 80% of HIV cases but only 2000 (14%) of the people in ART. In South and South-East Asia there were 1700 former/current IDUs receiving ART (1.8% of the people in ART), whereas the proportion of HIV cases associated to IDU is >20% in five countries (and regionally ranges from 4% to 75%). Discussion: There is evidence that the coverage of ART among current/former IDUs is proportionally substantially less than other exposure categories. Ongoing monitoring of ART by exposure and population subgroups is critical to ensuring that scale-up is equitable, and that the distribution of ART is, at the very least, transparent.

2 The African Evaluation Guidelines: 2002. A checklist to assist in planning evaluations, negotiating clear contracts, reviewing progress and ensuring adequate completion of an evaluation. Abstract: A review of the US ‗program evaluation standards‘ (PES), undertaken in a series of workshops and meetings of networks of evaluators in Africa, resulted in modifications to those standards. The result was presented to a plenary session of the Inaugural Conference of the African Evaluation Association in September 1999, attended by over 300 evaluators from 35 countries. The AfrEA Conference decided that a systematic effort should be made to produce a list of African evaluation guidelines, similar to the PES, and that this checklist should be reviewed by national evaluation associations and networks in Africa and field tested in several countries. Ten national and regional networks and associations suggested modifications to the text and endorsed the final version of the guidelines.

3 AIDS and public policy: the lessons and challenges of ‗success‘ in Thailand. Thailand's public policy on AIDS is widely cited as one of the few examples of an effective national AIDS prevention program anywhere in the world. The Thai experience shows that a national response that mobilized key government and NGO partners and targeted the highest-risk transmission can be effective in reducing the scope of the epidemic, even when action is delayed. Based on interviews with policymakers, AIDS program managers, technical specialists, donors, and NGOs and on a review of the data, we highlight the lessons from public policy on AIDS in Thailand for other developing countries, review the state of the Thai epidemic and public policy in 2000, and identify three strategic priorities for the next phase of the response.

4 Is it really working? HIV/AIDS, Global Initiatives, and the pressing challenge of evaluation. No abstract/summary (transcript of meeting)

5 Review of cost-effectiveness of Injecting Drug User interventions to prevent HIV in Asia. Background: The cost-effectiveness of IDU interventions to prevent HIV in Asia shows high return of investments: It costs PPP USD 27-289 per DALY. This is less than the cost of one year of antiretroviral treatment in Asia. Generally, the present coverage of IDU interventions is low and there is an urgent need to scale-up cost-effective IDU interventions. Objectives: 1) To analyse what we know on cost-effectiveness of IDU interventions to prevent HIV in the Asian region; 2) To explore the value of information generated by cost-effectiveness analysis at the level of planning and decision-making in a scale-up perspective; and 3) To recommend strategies to assist decision-makers in scaling up IDU interventions in Asia. Methodology: The analysis is based on findings from a literature survey on costing and cost-effectiveness studies in Asia and Eastern Europe, which is also characterized by concentrated HIV epidemics driven by high infection rates among IDUs and sex workers. The studies identified use the approach to costing of IDU interventions (ingredients approach producing unit cost per year) and the model to estimate the impact of IDU interventions: HIVTools, IDU Version 2.4. Results: IDU HIV interventions are very cost-effective at low coverage levels as demonstrated in the case of Karachi and at very high coverage levels as demonstrated in the case of CARE SHAKTI in Bangladesh. In the case of IDU interventions in Karachi, Pakistan, we find that the value for money is higher at the present low level of coverage than at higher levels of 30% and 60%. The comparative cost analysis of the IDU interventions in Asia reveal two major findings: (i) significant (unexplained) variation in unit costs between sites; and (ii) commodities are the dominant cost driver.

Discussion: This review shows that the best return of money is achieved if the scale-up of services is implemented at high coverage levels when the HIV prevalence rates are still low. Investing in IDU prevention interventions is not only a very cost- effective way of keeping this risk group free of HIV - it ensures that HIV is not spread to other risk groups and the general population through spouses and clients of sex workers. By focusing the 15 attention on IDUs and their partners (as this form of cost-effectiveness analysis does) the total impact of IDU HIV prevention interventions underestimates the wider public health gain. Cost-effectiveness analysis is an important tool in the priority setting process of strategic planning. However, much more work needs to be done in this field by assessing different approaches of IDU interventions to learn more on what works and what works best. One field of work where information is acutely needed in Asia is insights into the costs and consequences of including detoxification into the IDU programmes.

6 Hiv/aids‘ udbredelse og indflydelse på andre sundhedsrelaterede 2015-mål Hiv/aids er i dag den største trussel mod udvikling i lande med høj hiv-prævalens. I denne oversigtsartikel analyseres hiv‘s indflydelse på 2015-sundhedsmålene. Artiklen er baseret på et litteraturstudie om hiv‘s indflydelse på børnedødeligheden, mødredødeligheden samt udbredelsen af tuberkulose (tb) og malaria. Det konkluderes, at der kan påvises en stærk relation mellem hiv og børnedødelighed og hiv og tb. Sundhedsvæsenets strategi for at nå de enkelte 2015-mål bør derfor afspejle samspillet mellem forskellige sundhedsproblemer – herunder hvordan sundhedsvæsenet organiseres, og resurserne fordeles.

7 The Contribution of Sexual and Reproductive Health Services to the Fight against HIV/AIDS: A Review. Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.

8 Modelling the Impact of Antiretroviral Use in Resource-Poor Settings. Background: The anticipated scale-up of antiretroviral therapy (ART) in high-prevalence, resource constrained settings requires operational research to guide policy on the design of treatment programmes. Mathematical models can explore the potential impacts of various treatment strategies, including timing of treatment initiation and provision of laboratory monitoring facilities, to complement evidence from pilot programmes. Methods and Findings: A deterministic model of HIV transmission incorporating ART and stratifying infection progression into stages was constructed. The impact of ART was evaluated for various scenarios and treatment strategies, with different levels of coverage, patient eligibility, and other parameter values. These strategies included the provision of laboratory facilities that perform CD4 counts and viral load testing, and the timing of the stage of infection at which treatment is initiated. In our analysis, unlimited ART provision initiated at late-stage infection (AIDS) increased prevalence of HIV infection. The effect of additionally treating pre-AIDS patients depended on the behaviour change of treated patients. Different coverage levels for ART do not affect benefits such as life-years gained per person-year of treatment and have minimal effect on infections averted when treating AIDS patients only. Scaling up treatment of pre-AIDS patients resulted in more infections being averted per person-year of treatment, but the absolute number of infections averted remained small. As coverage increased in the models, the emergence and risk of spread of drug resistance increased. Withdrawal of failing treatment (clinical resurgence of symptoms), immunologic (CD4 count decline), or virologic failure (viral rebound) increased the number of infected individuals who could benefit from ART, but effectiveness per person is compromised. Only withdrawal at a very early stage of treatment failure, soon after viral rebound, would have a substantial impact on emergence of drug resistance. Conclusions: Our analysis found that ART cannot be seen as a direct transmission prevention measure, regardless of the degree of coverage. Counselling of patients to promote safe sexual practices is essential and must aim to effect long-term change. The chief aims of an ART programme, such as maximised number of patients treated or optimised treatment per patient, will determine which treatment strategy is most effective.

9 Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Summary:

Background: Male circumcision could provide substantial protection against acquisition of HIV-1 infection. Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related to this intervention. Methods: We did a randomised controlled trial of 2784 men aged 18–24 years in Kisumu, Kenya. Men were randomly assigned to an intervention group (circumcision; n=1391) or a control group (delayed circumcision, 1393), and assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV seroincidence was estimated in an intention-to-treat analysis. This trial is registered with ClinicalTrials.gov, with the number NCT00059371. Findings: The trial was stopped early on December 12, 2006, after a third interim analysis reviewed by the data and safety monitoring board. The median length of follow-up was 24 months. Follow-up for HIV status was incomplete for 240 (8·6%) participants. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped. The 2-year HIV incidence was 2·1% (95% CI 1·2–3·0) in the circumcision group and 4·2% (3·0–5·4) in the control group (p=0·0065); the relative risk of HIV infection in circumcised men was 0·47 (0·28–0·78), which corresponds to a reduction in the risk of acquiring an HIV infection of 53% (22–72). Adjusting for non-adherence to treatment and excluding four men found to be seropositive at enrolment, the protective effect of circumcision was 60% (32–77). Adverse events related to the intervention (21 events in 1·5% of those circumcised) resolved quickly. No behavioural risk compensation after circumcision was observed. Interpretation: Male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and affordable circumcision services should be integrated with other HIV preventive interventions and provided as expeditiously as possible.

10 Home-based HIV voluntary counseling and testing in developing countries (Review). ABSTRACT Background: The low uptake of HIV voluntary counseling and testing (VCT), an effectiveHIV prevention intervention, has hindered global attempts to prevent new HIV infections, as well as limiting the scale-up of HIV care and treatment for the estimated 38 million infected persons. According to UNAIDS, only 10% of HIV-infected individuals worldwide are aware of their HIV status. At this point in the HIV epidemic, a renewed focus has shifted to prevention, and with it, a focus on methods to increase the uptake of HIV VCT. This review discusses home-based HIV VCT delivery models, which, given the low uptake of facility-based testing models, may be an effective avenue to get more patients on treatment and prevent new infections. Objectives: (1) To identify and critically appraise studies addressing the implementation of home-based HIV voluntary counseling and testing in developing countries. (2) To determine whether home-based HIV voluntary counseling and testing (HBVCT) is associated with improvement in HIV testing outcomes compared to facility-based models. Search strategy: We searched online for published and unpublished studies in MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007). We also searched databases listing conference proceedings and abstracts; AIDSearch (February 2007), The Cochrane Library (Issue 2, 2007), LILACS, CINAHL and Sociofile. We also contacted authors who have published on the subject of review. Selection criteria: We searched for randomized controlled trials (RCTs) and non-randomized trials (e.g., cohort, pre/post- intervention and other observational studies) comparing home-based HIV VCT against other testing models. Data collection and analysis: We independently selected studies, assessed study quality and extracted data. We expressed findings as odds ratios (OR), and relative Risk (RR) together with their 95% confidence intervals (CI). Main results: We identified one cluster-randomized trial and one pre/post-intervention (cohort) study, which were included in the review. An additional two ongoing RCTs were identified. All identified studies were conducted in developing countries. The two included studies comprised one cluster-randomized trial conducted in an urban area in Lusaka, Zambia and one pre/post-intervention (cohort) study, part of a rural community cohort in Southwestern Uganda. The two studies, while differing in methodology, found very high acceptability and uptake of VCT when testing and or results were offered at home, compared to the standard (facility-based testing and results). In the cluster-randomized trial (n=849), subjects randomized to an optional testing location (including home-based testing) were 4.6 times more likely to accept VCT than those in the facility arm (RR 4.6, 95% CI 3.6-6.2). Similarly, in the pre/post study (n=1868) offering participants the option of home delivery of results increased VCT uptake. In the intervention year (home delivery) participants were 5.23 times more likely to receive their results than during the year when results were available only at the facility. (OR 5.23 95% CI 4.02-6.8). Authors’ conclusions: Home-based testing and/or delivery of HIV test results at home, rather than in clinics, appears to lead to higher uptake in testing. However, given the limited extant literature and the limitations in the included existing studies, there is not sufficient evidence to recommend large-scale implementation of the home-based testing model.

11 Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level.

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

12 Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part II: determinants operating at environmental and institutional level. This review summarises a wide range of evidence about environmental and institutional factors that influence vulnerability to malaria, tuberculosis, and HIV infection. By combining this information with that obtained on factors operating at individual, household, and community level, we have identified potential common strategies for improving resilience to all three diseases simultaneously. These strategies depend on collaborations with non-health sectors and include progress in rapid access to funds, provision of education about disease transmission and management, reduction of the burden on carers (predominantly women), and improvement in the quality of health services

13 Scaling up HIV/AIDS evaluation. No abstract

14 HIV/AIDS, sexual and reproductive health: intersections and implications for national programmes. HIV and AIDS have a myriad of effects on sexual and reproductive health and rights, and sexual and reproductive health services are critical for women and men with HIV and AIDS. Yet there has been a dearth of visible, in-depth mainstream attention to the links between sexual and reproductive health and prevention and treatment of HIV/AIDS since the early 1990s among major stakeholders internationally. This paper argues that access to essential sexual and reproductive health care should be provided in HIV/AIDS prevention, care and treatment programmes, and appropriate forms of prevention and treatment of HIV/AIDS should be included in all sexual and reproductive health services as a public health priority, particularly in sex education, family planning and abortion services, pregnancy-related care, sexually transmitted infection (STI) services and services addressing sexual violence. The paper analyzes existing barriers to linking and integrating these services, e.g. at country level due to the traditional training of health workers to implement vertical programmes, separate sources of funding for National AIDS Control Programmes and sexual and reproductive health services, and in international donor programme and UN agency structures. This paper calls for leadership to be exercised by donors, all the UN agencies working together, governments, health service managers and providers, NGOs and advocates in both fields to develop and implement these linkages at country level. Finally, it is crucial that UNAIDS, WHO, UNFPA, UNICEF, the Global Fund to Fight AIDS, TB and Malaria and those working to reach the targets set by the Millennium Development Goals come on board in these efforts.

15 A trickle or a Flood: Commitments and Disbursement for HIV/AIDS from the Global Fund, PEPFAR, and the World Bank‘s Multi-Country AIDS Program (MAP). This paper provides an analytical framework for understanding funders‘ disbursement policies and practices while also offering an overview of the total volume of resources being committed and disbursed by each funder. The analysis is focused on the global-level, but does provide brief country case studies to help understand some of the implications of these large inflows of funding for HIV/AIDS at the country-level. Key Findings: 1) Although the resources available for HIV/AIDS programs in developing countries is still far less than what is estimated to be required for a comprehensive global response, significant new funding has been made available in recent years. Analyses presented in this paper highlight the rapid increase in funding, and the dominance of the US PEPFAR program as a source of new monies. They also indicate how challenging it is to effectively use dramatically scaled-up resources in countries that have had historically very low levels of spending on health. 2) Since 2004, the Global Fund, PEPFAR, and the World Bank‘s MAP (ie. the big three) have been providing large volumes of new money for HIV/AIDS programs. By 2005, the three funders were transferring (ie disbursing) more than $3 billion per year, with over 70% of this total coming from PEPFAR. This money is provided by the funders in various ways to governments, local NGOs, international NGOs, consulting agencies, and other implementing entities. 3) The new resources provided by the big three funders represents a huge increase in funds at the country-level. In Uganda and Ethiopia, once AIDS money began flowing from all three funders in 2004, the amount of money provided quickly approached, and by 2005 had exceeded, the governments‘ 2003 budgets for the entire health sector. 4) The large scale of the new resources provided, and the differences among the funders in disbursement procedures, meant that money from the big three was difficult to manage in the two country cases examined in this paper, Ethiopia

and Uganda. The Global Fund, which has provided information to the public about in-country financial flows, found that both governments encountered challenges when trying to spend money: the use of resources was delayed, and accelerating progress in implementing the grant required turning to actors outside the government. 5) Total annual disbursements from the big three funders lag behind total annual commitments. This difference may be a result of the difficulty that recipients have had in absorbing large new sums of money. 6) Data availability varies by funder. PEPFAR does not provide disbursements data disaggregated by country. The World Bank and PEPFAR do not publicly release expenditure data for their recipients. The Global Fund does provide such expenditure data, which allows us to offer some preliminary insights about governments‘ capacity to manage AIDS funds in two country specific contexts.

16 Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries. This review systematically examined the effectiveness of 24 mass media interventions on changing human immunodeficiency virus (HIV)-related knowledge, attitudes and behaviors. The intervention studies were published from 1990 through 2004, reported data from developing countries and compared outcomes using (i) pre- and post-intervention data, (ii) treatment versus control (comparison) groups or (iii) postintervention data across levels of exposure. The most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behavior (eight), perceived risk of contracting HIV/acquired immunodeficiency syndrome (AIDS) (six), interpersonal communication about AIDS or condom use (six), selfefficacy to negotiate condom use (four) and abstaining from sexual relations (three). The results yielded mixed results, and where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is required to provide a more definitive answer to the question of media effects on HIV/AIDS-related behavior in developing countries.

17 A Global Review of the Business Response to HIV/AIDS 2005-2006.

Executive Summary (abbreviated): Key Findings: Nearly half of the respondents to the World Economic Forum‘s Executive Opinion Survey expect HIV/AIDS to have impacts on their business in the next five years Although worried about the future, few respondent firms have attempted to quantify the business risks due to HIV/AIDS. Outside the hardest hit countries, few firms have developed policies to tackle the virus In all regions, and regardless of national income and HIV prevalence, those firms that do have policies are much more confident in their ability to withstand the impacts of AIDS than firms without policies Recommendations for business - The results of the Executive Opinion Survey, along with case studies on good practice developed by the Global Health Initiative (GHI) of the World Economic Forum and an amfAR/Harris survey of US business leaders, point to the following challenges for businesses considering a response to HIV/AIDS: • Assess the threat • Develop a response & Start in the workplace • Link up with others • Address stigma • Look to the long term • Monitor and evaluate programmes Recommendations for the public, not-for-profit and non-governmental sectors: • Develop information resources to assist businesses • Disseminate models of good practice • Nurture partnerships with businesses and business associations • Develop resources to help businesses evaluate the effectiveness • Help businesses document results and showcase effective programmes

18 Approaches for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to- child human immunodeficiency virus transmission settings in resource-limited countries. Prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT) programs have nearly eliminated mother-to-child transmission of HIV in developed countries, but progress in resource-limited countries has been slow. A key factor limiting the scale-up of PMTCT programs is lack of knowledge of HIV serostatus. Increasing the availability and acceptability of HIV testing and counseling services will encourage more women to learn their status, providing a gateway to PMTCT interventions. Key factors contributing to the scale-up of testing and counseling include a policy of provider-initiated

testing and counseling with right to refuse (opt-out); group pretest counseling; rapid HIV testing; innovative staffing strategies; and community and male involvement. Integration of testing and counseling within the community and all maternal and child health settings are critical for scaling-up and for linking women and their families to care and treatment services. This paper will review best practices needed for expansion of testing and counseling in PMTCT settings in resource-limited countries.

19 GLOBAL FUND TRACKING STUDY Mozambique Tanzania Uganda Zambia COUNTRY. SUMMARIES and CONCLUSIONS No abstract

20 The Global Fund at three years – flying in crowded air space Editorial, no abstract/summary

21 Evaluation of HIV Programmes Editorial, no abstract/summary

22 Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. Background: The impact of antiretroviral therapy (ART) on sexual risk behavior and HIV transmission among HIV-infected persons in Africa is unknown. Objective: To assess changes in risky sexual behavior and estimated HIV transmission from HIV-infected adults after 6 months of ART. Design and methods: A prospective cohort study was performed in rural Uganda. Between May 2003 and December 2004 a total of 926 HIV-infected adults were enrolled and followed in a home-based ART program that included prevention counselling, voluntary counseling and testing (VCT) for cohabitating partners and condom provision. At baseline and follow- up, participants‘ HIV plasma viral load and partner-specific sexual behaviors were assessed. Risky sex was defined as inconsistent or no condom use with partners of HIV-negative or unknown serostatus in the previous 3 months. The rates of risky sex were compared using a Poisson regression model and transmission risk per partner was estimated, based on established viral loadspecific transmission rates. Results: Six months after initiating ART, risky sexual behavior reduced by 70% [adjusted risk ratio, 0.3; 95% confidence interval (CI), 0.2–0.7; P ¼ 0.0017]. Over 85% of risky sexual acts occurred within married couples. At baseline, median viral load among those reporting risky sex was 122 500 copies/ml, and at follow-up, < 50 copies/ml. Estimated risk of HIV transmission from cohort members declined by 98%, from 45.7 to 0.9 per 1000 person years. Conclusions: Providing ART, prevention counseling, and partner VCT was associated with reduced sexual risk behavior and estimated risk of HIV transmission among HIVinfected Ugandan adults during the first 6 months of therapy. Integrated ART and prevention programs may reduce HIV transmission in Africa.

23 The cost-effectiveness of Antiretroviral Treatment in Khayelitsha, South Africa – a primary data analysis. Abstract Background: Given the size of the HIV epidemic in South Africa and other developing countries, scaling up antiretroviral treatment (ART) represents one of the key public health challenges of the next decade. Appropriate priority setting and budgeting can be assisted by economic data on the costs and cost-effectiveness of ART. The objectives of this research were therefore to estimate HIV healthcare utilisation, the unit costs of HIV services and the cost per life year (LY) and quality adjusted life year (QALY) gained of HIV treatment interventions from a provider's perspective. Methods: Data on service utilisation, outcomes and costs were collected in the Western Cape Province of South Africa. Utilisation of a full range of HIV healthcare services was estimated from 1,729 patients in the Khayelitsha cohort (1,146 No- ART patient-years, 2,229 ART patient-years) using a before and after study design. Full economic costs of HIV-related services were calculated and were complemented by appropriate secondary data. ART effects (deaths, therapy discontinuation and switching to second-line) were from the same 1,729 patients followed for a maximum of 4 years on ART. No-ART outcomes were estimated from a local natural history cohort. Health-related quality of life was assessed on a sub- sample of 95 patients. Markov modelling was used to calculate lifetime costs, LYs and QALYs and uncertainty was assessed through probabilistic sensitivity analysis on all utilisation and outcome variables. An alternative scenario was constructed to enhance generalizability. Results: Discounted lifetime costs for No-ART and ART were US$2,743 and US$9,435 over 2 and 8 QALYs respectively. The incremental cost-effectiveness ratio through the use of ART versus No-ART was US$1,102 (95% CI 1,043-1,210) per QALY and US$984 (95% CI 913-1,078) per life year gained. In an alternative scenario where adjustments were made across cost, outcome and utilisation parameters, costs and outcomes were lower, but the ICER was similar.

Conclusion: Decisions to scale-up ART across sub-Saharan Africa have been made in the absence of incremental lifetime cost and cost-effectiveness data which seriously limits attempts to secure funds at the global level for HIV treatment or to set priorities at the country level. This article presents baseline cost-effectiveness data from one of the longest running public healthcare antiretroviral treatment programmes in Africa that could assist in enhancing efficient resource allocation and equitable access to HIV treatment.

24 Uptake of Workplace HIV Counselling and Testing: A Cluster-Randomised Trial in Zimbabwe. Background: HIV counselling and testing is a key component of both HIV care and HIV prevention, but uptake is currently low. We investigated the impact of rapid HIV testing at the workplace on uptake of voluntary counselling and testing (VCT). Methods and Findings: The study was a cluster-randomised trial of two VCT strategies, with business occupational health clinics as the unit of randomisation. VCT was directly offered to all employees, followed by 2 y of open access to VCT and basic HIV care. Businesses were randomised to either on-site rapid HIV testing at their occupational clinic (11 businesses) or to vouchers for off-site VCT at a chain of free-standing centres also using rapid tests (11 businesses). Baseline anonymised HIV serology was requested from all employees. HIV prevalence was 19.8% and 18.4%, respectively, at businesses randomised to on-site and off-site VCT. In total, 1,957 of 3,950 employees at clinics randomised to on-site testing had VCT (mean uptake by site 51.1%) compared to 586 of 3,532 employees taking vouchers at clinics randomised to off-site testing (mean uptake by site 19.2%). The risk ratio for on-site VCT compared to voucher uptake was 2.8 (95% confidence interval 1.8 to 3.8) after adjustment for potential confounders. Only 125 employees (mean uptake by site 4.3%) reported using their voucher, so that the true adjusted risk ratio for on-site compared to off-site VCT may have been as high as 12.5 (95% confidence interval 8.2 to 16.8). Conclusions: High-impact VCT strategies are urgently needed to maximise HIV prevention and access to care in Africa. VCT at the workplace offers the potential for high uptake when offered on-site and linked to basic HIV care. Convenience and accessibility appear to have critical roles in the acceptability of community-based VCT.

25 Infant human immunodeficiency virus diagnosis in resource-limited settings: issues, technologies, and country experiences. Diagnosing human immunodeficiency virus (HIV) infection in infants is difficult because maternal HIV antibodies cross the placenta, causing positive serologic tests in HIV-exposed infants for the first several months of life. Early definitive diagnosis of HIV requires virologic testing such as polymerase chain reaction (PCR), which is the diagnostic standard in resource-rich settings but has been too complex and expensive for widespread use in most countries with high HIV prevalence. Early PCR testing can help HIV-infected infants access treatment, provide psychosocial benefits for families of uninfected infants, and help programs for prevention of mother-to-child transmission of HIV monitor their effectiveness. HIV testing, including PCR, is increasingly available for infants in resource-limited settings, but there are many barriers and complex policy decisions that need to be addressed before universal early testing can become standard. This paper reviews challenges and progress in the field and suggests ways to facilitate early infant testing in resource-limited settings.

26 Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Summary Background: Evidence for cost-effectiveness of interventions for HIV/AIDS in Africa is fragmentary. Cost-effectiveness is, however, highly relevant. African governments face difficult choices in striking the right balance between prevention, treatment, and care, all of which are necessary to deal comprehensively with the epidemic. Reductions in drug prices have raised the priority of treatment, though treatment access is restricted. We assessed the existing costeffectiveness data and its implications for value-for-money strategies to combat HIV/AIDS in Africa. Methods: We undertook a systematic review using databases and consultations with experts. We identified over 60 reports that measured both the cost and effectiveness of HIV/AIDS interventions in Africa. 24 studies met our inclusion criteria and were used to calculate standardised estimates of the cost (US$ for year 2000) per HIV infection prevented and per disability-adjusted life-year (DALY) gained for 31 interventions. Findings: Cost-effectiveness varied greatly between interventions. A case of HIV/AIDS can be prevented for $11, and a DALY gained for $1, by selective blood safety measures, and by targeted condom distribution with treatment of sexually transmitted diseases. Single-dose nevirapine and short-course zidovudine for prevention of mother-to-child transmission, voluntary counselling and testing, and tuberculosis treatment, cost under $75 per DALY gained. Other interventions, such as formula feeding for infants, home care programmes, and antiretroviral therapy for adults, cost several thousand dollars per infection prevented, or several hundreds of dollars per DALY gained. Interpretation: A strong economic case exists for prioritisation of preventive interventions and tuberculosis treatment. Where potentially exclusive alternatives exist, cost-effectiveness analysis points to an intervention that offers the best value for money. Cost-effectiveness analysis is an essential component of informed debate about priority setting for HIV/AIDS.

27 Health System Strengthening and Scaling Up Antiretroviral Therapy: The Need for Context-Specific Delivery Models: Comment on Schneider et al. Comment – no abstract

28 Review of the Danish Support to HIV/AIDS-related activities in programme countries - Country Case Studies: Uganda. Assessment and Conclusions: Uganda is now well into a phase of its HIV/AIDS epidemic, where, after the impressive decline of the national prevalence figures over a number of years, these figures have now been more or less stable for 3 to 4 years, where the number of deaths is still high and growing, and where the problems posed by the huge and increasing number of orphans are becoming more and more acute. The widely acclaimed success of Uganda to bring down the HIV/AIDS prevalence therefore does still not leave room for complacency. An effective national response is as essential as ever, although its direction and approaches will need to change compared to the past. Apart from the challenge arising from the increasing demand for care and treatment, in particular ARV treatment, the social, economic, and psycho-social challenges will have to be increasingly attended to. This is not least due to the huge problems posed by the 10% of the population, which is orphaned mostly due to AIDS, problems that are not given sufficient attention at present, and which threaten to be even more overshadowed by the focus now put on treatment and care. Not least the scaling up of ARV treatment may well sideline other important concerns, especially those, which are of a longer-term nature like that of the orphans. Looking at the formal coordination and leadership set-up of the Ugandan national HIV/AIDS response, there is hardly any doubt, that it represents a case of best practise in its field. This is in spite of the fact, that there are still significant amounts of work to be done in order to bring it up to full capacity and effectiveness. The M & E system is one of the important weaknesses. Underneath the surface, however, the unity of the system is undercut by the fact, that two of the three really huge providers of funds for the response do not respect the principle of the ―three ones‖ and keep their support more or less outside the coordinating structures. To make things worse, this way of acting corroborates existing cleavages and rivalries among Ugandan institutions. In reality, therefore, the national response is threatening to become fragmented rather than comprehensive and united. This will inevitably reduce the efficiency and effectiveness of the response, and it will make it even more difficult to cope with the distortions created through the huge injection of funds for some, but not other parts of the response. It will also create problems, which can be literally life-threatening, on the demand side, i.e. among the patients, their families and communities: They will be faced with the complexities and inflexibilities caused by several different supply chains and service providers issuing different medicines, following different approaches to follow-up, etc., and making it difficult or impossible for patients to switch provider. The Danish support to the response is satisfactory in some respects and less so in others. On the whole, however, the support appears to be well situated within the total – and rapidly changing - picture of donor funding and in line with present and emerging needs. As for the effort to integrate and mainstream HIV/AIDS in the sector programmes, the ASPS is clearly leading the way in so far as specific and targeted activities are concerned and has produced lessons, that ought to be shared more widely within and outside Uganda. In the road sector, work on HIV/AIDS has been done for some years, and there is scope for intensifying the effort after the programme has now assisted the ministry to produce a plan for the mainstreaming process. Denmark appears to by the leading player in getting HIV/AIDS integrated in the approaches used nationally in the road sector. This is in contrast to the PS Programme, which lags behind in its contribution to the HIV/AIDS response. In the health sector, lastly, the focus is on supporting the development of the national health system as a whole, which is absolutely essential if the HIV/AIDS response within the fields of care and treatment is to be scaled up as envisaged. In addition, there is targeted support for the drug supply system, one of the particularly critical pieces in the puzzle of getting the response scaled up. The Danish support to the health sector could thus hardly be used much better from the point of view of facilitating the HIV/AIDS response. Outside the sector programmes, the support to good governance up to now has a mixed record, but with the merging of the various projects under a common strategy later this year, the issue of HIV/AIDS stands to be integrated better in all the components. A particularly important history of Danish support is found in the case of TASO, where the present contribution is through a basket-funding arrangement with other donors, that provides for a flexibility which is particularly important for the organisation now, as narrowly targeted funding has become a dominating modality (PEPFAR, GFATM, MAP). A review later in the year will determine how to continue the support. Some interesting and strategic interventions are also being funded from local appropriations, not least the work of the NGO ―Straight Talk‖ and some of the projects carried out by UNICEF. These are examples of areas of work, which appear not to attract sufficient support at present, and where the Danish funding therefore seems to be particularly important and would merit expansion in the future.

There is however no comprehensive overview of the implementation and funding of the national response. It is therefore difficult to know, whether other areas than those supported are more in need. In the area of orphans, for example, which is huge, complicated, and central to managing the long-term consequences of the epidemic, the GFATM has agreed to inject as much as USD 56 million (although it may take some time, before the funds start flowing). This is clearly more than can at present be handled by the weak Ministry of Gender, Labour and Social Development, and if the Danish support to the hiv/aids response were to increase, support for capacity development within this ministry might be warranted. The types of community activities presently funded from the MAP loan might also be worth giving additional support, and the option of transforming the MAP funding arrangement to a basket for other donors as well, could be explored. Such a move would also provide a chance to reduce the diversity in funding arrangements, and thereby strengthen the UAC in its coordinating role. The mapping of the response combined with the costing of the revised NSF, both exercises planned for this year, should provide a better picture of the needs and priorities for future Danish funding, as well as an indication of whether to increase the funds available for HIV/AIDS compared to at present. Looking at the human, organisational, and logistical capacity of the health sector, the only immediately obvious area, that will receive more than sufficient funding over the coming years is the one of ARV treatment. In general terms, therefore, Danish funds should continue not to be allocated to treatment as such, but to the development of the health sector capacity to cope with ARV (as well as with those other issues that risk to be sidelined by the massive scaling up of ARV treatment) and to strategic and neglected priority activities outside the health sector. In both cases, the modalities should be chosen so as to promote national leadership within the framework of the Partnership. It is also important to be aware that any support for the general functioning and improved efficiency and productivity of the public sector as a whole is a contribution to the HIV/AIDS response in terms of increasing its coping capacity.

29 The Prevention and Control of HIV/AIDS, TB and Vector-borne Diseases in Informal Settlements: Challenges, Opportunities and Insights. Abstract: Today‘s urban settings are redefining the field of public health. The complex dynamics of cities, with their concentration of the poorest and most vulnerable (even within the developed world) pose an urgent challenge to the health community. While retaining fidelity to the core principles of disease prevention and control, major adjustments are needed in the systems and approaches to effectively reach those with the greatest health risks (and the least resilience) within today‘s urban environment. This is particularly relevant to infectious disease prevention and control. Controlling and preventing HIV/AIDS, tuberculosis and vector-borne diseases like malaria are among the key global health priorities, particularly in poor urban settings. The challenge in slums and informal settlements is not in identifying which interventions work, but rather in ensuring that informal settlers: (1) are captured in health statistics that define disease epidemiology and (2) are provided opportunities equal to the rest of the population to access proven interventions. Growing international attention to the plight of slum dwellers and informal settlers, embodied by Goal 7 Target 11 of the Millennium Development Goals, and the considerable resources being mobilized by the Global Fund to fight AIDS, TB and malaria, among others, provide an unprecedented potential opportunity for countries to seriously address the structural and intermediate determinants of poor health in these settings. Viewed within the framework of the social determinants of disease^ model, preventing and controlling HIV/AIDS, TB and vectorborne diseases requires broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes for the urban poor. We examine insights into effective approaches to disease control and prevention within poor urban settings under a comprehensive social development agenda.

30 Determinants of adherence to highly active antiretroviral therapy among HIV-1-infected patients in Côte d‘Ivoire. Objective: To assess adherence to HAART and to determine factors associated with poor adherence among HIV-1-infected patients in Abidjan, Côte d‘Ivoire. Methods: A prospective observational study of 614 consecutive patients attending an HIV/AIDS outpatient clinic. Adherence was measured twice at 3-month intervals by self-report of missing doses over 4 days. An adherence level of less than 95% was defined as poor adherence. We used generalized estimating equation models for binomial distribution with repeated measures for data analysis. Results: Of the 591 subjects who completed the study, 74.3% reported adherence levels of 95% or greater. Six factors were independently related to poor adherence: age less than 35 years [relative risk (RR) 1.45; 95% confidence interval (CI) 1.17– 1.79], absence of social support (RR 1.66; 95% CI 1.24–2.24), number of daily pills 10 or more (RR 1.47; 95% CI 1.14– 1.91), time of adherence assessment (first versus second time assessment RR 1.36; 95% CI 1.12–1.66), CD4 cell count of 250 cells/ml or greater (RR 1.43; 95% CI 1.10–1.88), and not being less worried about HIV infection now that treatments

have improved (RR 1.26; 95% CI 1.01–1.58). Drug supply interruptions in the pharmacies were reported by 10.0% of the non-adherent patients as the reason for missing pills. Conclusion: Psychosocial factors were found to impact adherence and should be analysed in more detail by further studies. Scaling up antiretroviral therapy in sub-Saharan Africa should be preceded by reliable drug supply and distribution systems.

31 Seizing the Big Missed Opportunity: Linking HIV and Maternity Care Services in Sub-Saharan Africa. This paper draws on two reviews commissioned by the UK Department for International Development in 2006–2007 that explore progress in linking HIV prevention and maternity services in sub-Saharan Africa. Although pilot and demonstration projects have been successful, progress in scaling up PMTCT has been slow, reaching just 11% of pregnant HIV positive women in much of Africa, less than half the percentage of coverage achieved by antiretroviral treatment programmes for adults in need. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.

32 The Science of Microbicides: Accelerating Development Executive Summary’s Conclusions and recommendations: After more than a decade of research and development, the microbicides field is looking increasingly bright. An explosion of basic scientific research has identified many promising biological targets, encompassing a wide variety of mechanisms of action. Within each of these mechanisms of action, many new compounds are under active development. A wide variety of in vitro and animal models are now available to vet these products before clinical testing, and these models are continually being refined to improve their internal comparability and their specific relevance to human infection. Significant progress has also been made in the process of bringing a potential lead compound to market. There have been important clarifications of the requirements for pre-clinical testing of safety and efficacy. The regulatory pathway for human studies is also becoming more transparent (at least up to the evaluation of a large phase 3 efficacy study, which has to date been completed only for existing spermicidal products containing nonoxynol- 9). Finally, a substantial level of consensus has developed around the appropriate design of clinical trials and the ethical standards that apply to their conduct and management. Despite this dramatic progress in the overall product development effort, the concept of a topical microbicide for preventing the transmission of HIV and other sexually transmitted infections has yet to be clinically proved. No major pharmaceutical firm has yet made a significant investment in developing a microbicide product, and public-sector support has fallen well short of providing the funding required for optimal progress. The recommendation of the Science Working Group have therefore focused on identifying specific areas for investment to accelerate the development of a first-generation microbicide. These key areas are: 1. Improved funding for large-scale clinical effectiveness trials 2. Continued development of a robust and dynamic clinical trials infrastructure 3. Greater support and coordination of formulation, manufacturing, and delivery resources, on behalf of the entire field 4. Increased resources specifically devoted to the toxicological and pharmacodynamic testing of products currently in early development 5. Improved access by product sponsors to a coordinated program of animal and in vitro tests 6. Sustained resources for the development of microbicides through several product generations, in order to allow the field eventually to become commercially selfsustaining Next steps: Accelerating the development of microbicides is a realistic and important near-term opportunity. The challenges facing microbicide development are well understood and manageable. The first generation of microbicide products is now undergoing clinical testing, and, if effective, should be on the market well within this decade. Subsequent product generations will deliver improved effectiveness, a broader spectrum of activity, and enhanced acceptability for consumers. In addition, once clinical effectiveness for a lead product has been established, market mechanisms are likely to support most subsequent product development (although public support for access in resource-poor settings will probably be required in order to achieve the greatest possible public health benefit). Proving clinical effectiveness in the first place, however, and demonstrating that microbicides can offer a valuable weapon in the fight against AIDS and other sexually transmitted infections, is likely to require significantly greater resources than are currently being devoted to the field. As this document demonstrates, the science

behind microbicides is developing rapidly, and the process for developing a marketable product is becoming increasingly clear. The only missing ingredient for developing a safe, effective, and accessible microbicide is sufficient investment and the sustained will to see these products created. As a global health priority, it is imperative that these ingredients do not remain missing for long.

33 Mainstreaming HIV/AIDS in development sectors: Have we learnt the lessons from gender mainstreaming? Abstract: Drawing on an international literature review, two international workshops and primary qualitative research in Uganda this paper reviews experiences of mainstreaming HIV/AIDS in development sectors (such as education, health and agriculture) in developing countries. The extent to which HIV/AIDS mainstreaming strategies and associated challenges are similar to or different from those of mainstreaming gender in the health sector is also explored. The paper details the rationale for HIV/AIDS mainstreaming through illustrating the wide reaching effects of the pandemic. Despite the increasing interest in mainstreaming HIV/AIDS there is little clarity on what it actually means in theory or practice. This paper presents a working definition of HIV/AIDS mainstreaming. It is argued that all too often processes of ‗mainstreaming‘ emerge as too narrow and reductionist to be effective. The paper then considers four key challenges for mainstreaming HIV/AIDS and explores how and to what extent they have also been faced in gender mainstreaming and what can be learnt from these experiences. These are: (1) the limited evidence base upon which to build mainstreaming strategies in different country contexts; (2) the role of donors in mainstreaming and implications for sustainability; (3) who should take responsibility for mainstreaming; and (4) how to develop capacity for mainstreaming. The conclusion argues for more joined up thinking and sustainable approaches to mainstreaming both HIV/AIDS and gender.

34 Are we spending too much on HIV? No abstract – short article.

35 HIV antiretroviral therapy: can franchising expand coverage? No abstract/resumé

36 Micronutrient interventions and HIV infection: a review of current evidence. Objective: To review the current evidence on the role of micronutrient supplementation in HIV transmission and progression. Method: Literature review. Results: The importance of micronutrients in the prevention and treatment of childhood infections is well known, and evidence is emerging that micronutrient interventions may also affect HIV transmission and progression. Conclusion: Interventions to improve micronutrient intake and status could contribute to a reduction in the magnitude and impact of the global HIV epidemic. However, more research is needed before specific recommendations can be made.

37 School-based HIV prevention programmes for African youth. Abstract: The high rate of HIV infection among youth in Africa has prompted both national and international attention. Education and prevention programmes are seen as the primary way of decreasing this rate. This paper reviews 11 published and evaluated school-based HIV/AIDS risk reduction programmes for youth in Africa. Most evaluations were quasi-experimental designs with pre–post test assessments. The programme objectives varied, with some targeting only knowledge, others attitudes, and others behaviour change. Ten of the 11 studies that assessed knowledge reported significant improvements. All seven that assessed attitudes reported some degree of change toward an increase in attitudes favourable to risk reduction. In one of the three studies that targeted sexual behaviours, sexual debut was delayed, and the number of sexual partners decreased. In one of the two that targeted condom use, condom use behaviours improved. The results of this review suggest that knowledge and attitudes are easiest to change, but behaviours are much more challenging. The article provides details about programmes and identifies characteristics of the most successful programmes. Clearly, however, more research is needed to identify, with certainty, the factors that drive successful school- based HIV/AIDS risk reduction programmes in Africa.

38 Building evaluation capacity for HIV prevention programs. HIV prevention programs, even those using science-based interventions, need to conduct evaluation to support the implementation and transfer of effective interventions, account for services, demonstrate effectiveness, and improve programs. The Program Evaluation Research Branch of the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, assists health department grantees and other CDC grantees by providing evaluation guidance, technical assistance (TA), and training in order to build their HIV prevention program evaluation capacity. Together, these evaluation resources assist grantees with overall implementation of evaluation and identify specific types of evaluation appropriate to each stage of intervention development. This paper describes the evaluation developmental process for different types of evaluation activities, provides a framework for building evaluation

capacity, discusses the evaluation resources provided by CDC and gives examples of how evaluation TA and training support the overall technology transfer goals.

39 Global Mobilization for HIV Prevention - a blueprint for action. Projections by a research group led by WHO and UNAIDS, published in The Lancet in July 2002, indicate that the global HIV infection rate will continue its rapid pace, producing 45 million new infections between 2002 and 2010. The analysis also states that this scenario is in no way inevitable. In fact, 28 million (63 percent) of these new infections could be prevented if existing HIV prevention strategies are substantially scaled up,1 and even more could be averted with the advent of new prevention technologies. The Global HIV Prevention Working Group— composed of leading experts in public health, clinical care, biomedical, behavioral, and social research, and people affected by HIV/AIDS, and convened by the Bill & Melinda Gates Foundation and the Henry J. Kaiser Family Foundation—seeks to generate a greatly expanded commitment to preventing HIV transmission as part of a comprehensive approach to fighting the global epidemic. The world knows much about how to prevent HIV transmission, and both developed and developing countries have demonstrated that existing prevention strategies can have a major impact. This ―blueprint for action‖—the first report of the Working Group—provides a road map for rapidly scaling up prevention programs to contain and ultimately reverse the AIDS epidemic. The report reviews the scientific literature on the effectiveness of HIV prevention interventions, identifies obstacles to quickly expanding prevention programs, and makes specific recommendations to prevent millions of infections this decade.

40 New approaches to HIV prevention. The Global hiv Prevention Working Group is a panel of 50 leading public health experts, clinicians, biomedical and behavioral researchers, and people affected by hiv/aids, convened by the Bill & Melinda Gates Foundation and the Henry J. Kaiser Family Foundation. The Working Group seeks to inform global policy-making, program planning, and donor decisions on hiv prevention, and to advocate for a comprehensive response to hiv/aids that integrates prevention, treatment, and care. Working Group publications are available at www.gatesfoundation .org and www.kff.org. Long Executive Summary is available in Report

41 Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Summary Background: The probability of HIV-1 transmission per coital act in representative African populations is unknown. We aimed to calculate this probability overall, and to estimate how it is affected by various factors thought to influence infectivity. Methods: 174 monogamous couples, in which one partner was HIV-1 positive, were retrospectively identified from a population cohort in Rakai, Uganda. Frequency of intercourse and reliability of reporting within couples was assessed prospectively. HIV-1 seroconversion was determined in the uninfected partners, and HIV-1 viral load was measured in the infected partners. Adjusted rate ratios of transmission per coital act were estimated by Poisson regression. Probabilities of transmission per act were estimated by log-log binomial regression for quartiles of age and HIV-1 viral load, and for symptoms or diagnoses of sexually transmitted diseases (STDs) in the HIV-1-infected partners. Results: The mean frequency of intercourse was 8·9 per month, which declined with age and HIV-1 viral load. Members of couples reported similar frequencies of intercourse. The overall unadjusted probability of HIV-1 transmission per coital act was0·0011 (95% CI 0·0008–0·0015). Transmission probabilities increased from 0·0001 per act at viral loads of less than 1700 copies/mL to 0·0023 per act at 38 500 copies/mL or more (p=0·002), and were 0·0041 with genital ulceration versus 0·0011 without (p=0·02). Transmission probabilities per act did not differ significantly by HIV-1 subtypes A and D, sex, STDs, or symptoms of discharge or dysuria in the HIV-1-positive partner. Interpretation: Higher viral load and genital ulceration are the main determinants of HIV-1 transmission per coital act in this Ugandan population.

42 Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Background: Ecological and observational studies suggest that male circumcision reduces the risk of HIV acquisition in men. Our aim was to investigate the effect of male circumcision on HIV incidence in men. Methods: 4996 uncircumcised, HIV-negative men aged 15–49 years who agreed to HIV testing and counselling were enrolled in this randomised trial in rural Rakai district, Uganda. Men were randomly assigned to receive immediate circumcision (n=2474) or circumcision delayed for 24 months (2522). HIV testing, physical examination, and interviews were repeated at 6, 12, and 24 month follow-up visits. The primary outcome was HIV incidence. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, with the number NCT00425984. Findings: Baseline characteristics of the men in the intervention and control groups were much the same at enrolment. Retention rates were much the same in the two groups, with 90–92% of participants retained at all time points. In the modified intention-to-treat analysis, HIV incidence over 24 months was 0·66 cases per 100 person-years in the intervention

group and 1·33 cases per 100 person-years in the control group (estimated efficacy of intervention 51%, 95% CI 16–72; p=0·006). The as-treated effi cacy was 55% (95% CI 22–75; p=0·002); effi cacy from the Kaplan-Meier time-to-HIV-detection as-treated analysis was 60% (30–77; p=0·003). HIV incidence was lower in the intervention group than it was in the control group in all sociodemographic, behavioural, and sexually transmitted disease symptom subgroups. Moderate or severe adverse events occurred in 84 (3·6%) circumcisions; all resolved with treatment. Behaviours were much the same in both groups during follow-up. Interpretation: Male circumcision reduced HIV incidence in men without behavioural disinhibition. Circumcision can be recommended for HIV prevention in men.

43 10 best resources in . . . cost analysis for HIV/AIDS programmes in low and middle income countries. Conclusion: Cost analysis of HIV/AIDS programmes is still in its infancy. Compared to the thousands of interventions that are in motion, only a handful of individual programme cost analyses exist. The tide is shifting though, and more people are becoming aware of the benefits and multiple uses of costing studies. As the number of studies based on standardized methodology increase, programme planners at all levels will have better information on what interventions cost, their impact on HIV transmission, and the trade-offs of particular strategies. Using guidelines and tracking the current state of knowledge is vital to improve costing for transparency and informed decision-making. These references should help any analyst to do so.

44 Setting and organization of care for persons living with HIV/AIDS (Review). ABSTRACT Background: Treating the world‘s 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multidisciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood. Objectives: Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS. Search strategy: Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages. Selection criteria: Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS. Data collection and analysis: Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis. Main results: Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed. Authors’ conclusions: Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

45 AIDS and ―shared sovereignty‖ in Tanzania from 1987 to 2000: a case study. Abstract: After more than 15 years of foreign assistance to support HIV/AIDS prevention in Sub-Saharan Africa, HIV rates in the sub-continent remain high with only a few examples of reduced HIV incidence. This case study used the frame of ―shared sovereignty‖ between nation- states and official development assistance agencies to analyze 13 years of technical assistance for HIV/AIDS programs in Tanzania from 1987 to 2000. The study draws on 21 key informant interviews and a systematic review of key program documents from the National AIDS Control Programme (NACP) and 14 other international agencies. Applying Jamison et al.'s (Lancet 351 (1998) 514) shared sovereignty framework, the analysis focused on fulfilled shared functions in moving Tanzania's NACP from dependence to independence. The analysis revealed an uneven and inconsistent level of technical assistance to the NACP with a rotation of multilateral and bilateral donors over the period of study. The Tanzanian

government was often ambivalent toward agencies providing assistance towards its HIV/AIDS programs and toward its own NACP. Results are discussed in terms of implications for future strategic planning to mitigate the effects of HIV/AIDS. Determining roles, shared accountability and responsibility in a shared sovereignty framework remain a challenge in the governance of HIV/AIDS programs in Tanzania.

46 Continued correspondence ‗Will ART rollout in Africa drive an epidemic of drug-resistant HIV?‘. Short correspondence, no abstract.

47 Condom Promotion for AIDS Prevention in the Developing World: Is It Working? Two decades of experience and research provide new insights into the role of condoms for AIDS prevention in the developing world. This literature review and synthesis is based on computerized searches of the scientific literature and review of conference presentations, publications of national and international organizations, and popular media. Condoms are about 90 percent effective for preventing HIV transmission, and their use has grown rapidly in many countries. Condoms have produced substantial benefit in countries like Thailand, where both transmission and condom promotion are concentrated in the area of commercial sex. The public health benefit of condom promotion in settings with widespread heterosexual transmission, however, remains unestablished. In countries like Uganda that have curbed generalized epidemics, reducing the number of individuals‘ sex partners appears to have been more important than promoting the use of condoms. Other countries continue to have high rates of HIV transmission despite high reported rates of condom use among the sexually active. The impact of condoms may be limited by inconsistent use, low use among those at highest risk, and negative interactions with other strategies. Recommendations include increased condom promotion for groups at high risk, more rigorous measurement of the impact of condom promotion, and more research on how best to integrate condom promotion with other prevention strategies.

48 Estimating health workforce needs for antiretroviral therapy in resource-limited settings. Abstract Background: Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes. Methods: We reviewed the published literature and selected plans and scaling-up proposals, interviewed experts and collected data on staffing patterns at existing treatment sites through a structured survey and site visits. Results: We found a wide range of staffing patterns and patient-provider ratios in existing and planned treatment programmes. Many factors influenced health workforce needs, including task assignments, delivery models, other staff responsibilities and programme size. Overall, the number of health care workers required to provide ART to 1000 patients included 1–2 physicians, 2–7 nurses, <1 to 3 pharmacy staff, and a much wider range of counsellors and treatment supporters. We estimate from these data that the equivalent of 20 000 to 100 000 physicians, nurses, pharmacists and other core clinical staff will be needed to meet the WHO target of treating 3 million people by the end of 2005. The total number of staff, including counsellors, administrators and other cadres, could be substantially higher. Discussion: These data are consistent with other estimates of human resource requirements for antiretroviral therapy, but highlight the considerable variability of current staffing models and the importance of a broad range of factors in determining personnel needs. Few outcome or cost data are currently available to assess the effectiveness and efficiency of different staffing models, and it will be important to develop improved methods for gathering this information as treatment programmes are scaled up.

49 Achieving the global goals on HIV among young people most at risk in developing countries: young sex workers, injecting drug users and men who have sex with men. Objective: To review evaluations of interventions in developing countries targeting three groups most at risk of becoming infected with HIV: young sex workers, young injecting drug users and young men who have sex with men. Methods: A systematic literature review was undertaken to identify programmes in developing countries targeting young people in the three selected groups most at risk from HIV. We also identified programmes directed at young people in developed countries as well as programmes in developing countries that targeted these three population groups but that did not differentiate between young people and adults. Findings: Young people 10 to 24 years of age represent a large proportion of the population most at risk of becoming infected with HIV in developing countries. Despite this fact, well documented evaluations of interventions that target these

groups are scarce. However, there is evidence of effectiveness for programmes that are facility-based and use outreach to provide information and services to at-risk young people. Conclusion: There is growing evidence from developing countries of successful interventions that target groups most at risk from HIV, and these programmes should be widely implemented provided that they are carefully planned and monitored and have a strong evaluation component. However, there is an urgent need to disaggregate data by age in order to determine how effective these programmes are in reaching young people and to better understand the specific needs of at-risk young people as opposed to older age groups.

50 Achieving the millennium development goals for health - Cost effectiveness analysis of strategies to combat HIV/AIDS in developing countries. Abstract Objective: To assess the costs and health effects of a range of interventions for preventing the spread of HIV and for treating people with HIV/AIDS in the context of the millennium development goal for combating HIV/AIDS. Design: Cost effectiveness analysis based on an epidemiological model. Setting: Analyses undertaken for two regions classified using the WHO epidemiological grouping—Afr-E, countries in sub- Saharan Africa with very high adult and high child mortality, and Sear-D, countries in South East Asia with high adult and high child mortality. Data sources: Biological and behavioural parameters from clinical and observational studies and population based surveys. Intervention effects and resource inputs based on published reports, expert opinion, and the WHO-CHOICE database. Main outcome measures: Costs per disability adjusted life year (DALY) averted in 2000 international dollars ($Int). Results: In both regions interventions focused on mass media, education and treatment of sexually transmitted infections for female sex workers, and treatment of sexually transmitted infections in the general population cost < $Int150 per DALY averted. Voluntary counselling and testing costs < $Int350 per DALY averted in both regions, while prevention of mother to child transmission costs < $Int50 per DALY averted in Afr-E but around $Int850 per DALY in Sear-D. School based education strategies and various antiretroviral treatment strategies cost between $Int500 and $Int5000 per DALY averted. Conclusions: Reducing HIV transmission could be done most efficiently through mass media campaigns, interventions for sex workers and treatment of sexually transmitted infections where resources are most scarce. However, prevention of mother to child transmission, voluntary counselling and testing, and school based education would yield further health gains at higher budget levels and would be regarded as cost effective or highly cost effective based on standard international benchmarks. Antiretroviral therapy is at least as cost effective in improving population health as some of these interventions.

51 Joint Modeling of Progression of HIV Resistance Mutations Measured with Uncertainty and Failure Time Data. Summary. Development of HIV resistance mutations is a major cause for failure of antiretroviral treatment. This article proposes a method for jointly modeling the processes of viral genetic changes and treatment failure. Because the viral genome is measured with uncertainty, a hidden Markov model is used to fit the viral genetic process. The uncertain viral genotype is included as a time-dependent covariate in a Cox model for failure time, and an expectation-maximization algorithm is used to estimate the model parameters. This model allows simultaneous evaluation of the sequencing uncertainty and the effect of resistance mutation on the risk of virological and immunological failures. Various model checking tests are provided to assess the appropriateness of the model. Simulation studies are performed to investigate the finite-sample properties of the proposed methods, which are then applied to data collected in three phase II clinical trials testing antiretroviral treatments containing the drug efavirenz.

52 Efficacy of Antiretroviral Therapy Programs in Resource-Poor Settings: A Meta-analysis of the Published Literature. Background: Despite the advent of effective combination antiretroviral drug therapy (ART) for the treatment of human immunodeficiency virus (HIV) infection, many doubt the feasibility of ART treatment programs in resource-poor settings. We performed a meta-analysis of the efficacy of ART programs in the developing world. We searched the Medline database with the index terms ―HIV,‖ ―antiretroviral therapy,‖ ―CD4 count,‖ ―viral load,‖ ―experience,‖ and ―outcomes.‖ A total of 201 abstracts were reviewed, and 25 articles were selected for detailed review. Ten observational studies with details on patient outcomes were ultimately included in the analysis. Methods: Three readers independently extracted data from the articles. The details recorded included patient demographic characteristics, baseline CD4 cell counts, baseline HIV RNA viral loads, ART histories, outcomes, and timing of the outcome measure.

Results: The proportion of subjects with an undetectable HIV viral load provided the measure of treatment efficacy. A random-effects model weighted the proportion of patients with undetectable viral load at various time points during ART. The proportion was 0.697 (95% CI, 0.582–0.812) at month 6 and 0.573 (95% CI, 0.432–0.715) at month 12 of ART. The provision of medications free of charge to the patient was associated with a 29%–31% higher probability of having an undetectable viral load at months 6 and 12 than was the requirement that patients pay part or all of the cost of therapy. Conclusions: ART treatment programs in resource-poor settings have efficacy rates similar to those reported for developed countries. The provision of medications free of charge to the patient is associated with a significantly increased probability of virologic suppression at months 6 and 12 of ART.

53 Male circumcision in HIV Prevention. Correspondences - no abstracts

54 The impact of HIV treatment on risk behaviour in developing countries: A systematic review. Abstract In developing countries, access to antiretroviral therapy (ART) is improving as HIV treatment becomes a greater priority in the global fight against AIDS. While ART has clearly beneficial clinical effects, increased access to treatment may also affect sexual behaviour. To examine the strength of evidence for the impact of medical treatment for HIV-positive individuals on behavioural outcomes in developing countries, we conducted a comprehensive search of the peer-reviewed literature. Studies were included if they provided clinical treatment to HIV-positive individuals in a developing country, compared behavioural, psychological, social, care, or biological outcomes related to HIV-prevention using a pre/post or multi-arm study design, and were published between January 1990 and January 2006. Only three studies were identified that met the inclusion criteria. All were conducted in Africa, utilized before/after or multi-arm study designs, and relied on self-reported behaviour. In all three studies, a majority of HIV-infected individuals reported being sexually abstinent, and access to ART was not associated with an increase in HIV-related risky sexual behaviours. However, one cross-sectional study found that ART patients were more likely to report STD treatment. The available evidence indicates a significant reduction in risk behaviour associated with ART in developing countries. However, there are few existing studies and the rigor of these studies is weak. More studies are needed to build an evidence base on which to make programmatic and policy decisions.

55 The Economic Returns To Investing In Youth In Developing Countries: A Review of the Literature Abstract: This is a companion report to Assessing the Economic Returns to Investing in Youth in Developing Countries (Knowles and Behrman, 2003), with focus on the literature reviewed and greater detail in some parts than in the 2003 study. Both papers explore the economic case for investments in youth in developing countries. The current cohort of youth is the largest cohort ever. The economic, social, and demographic context of their lives has undergone enormous change, thus requiring a rethinking and re-evaluation of the range of investments in youth. This reappraisal must incorporate a number of critical features including recognition of the wide range of youth investments, the considerable lag in effects, and the likelihood that youth investments in one area affect investments and behavior in other areas. The paper examines forty-one investments in the following broad categories: formal schooling; civilian and military training, work; reproductive health; school-based health; other health; and community and other. The paper develops a lifecycle approach using cost-benefit analysis to calculate the economic returns to investments in youth. However, the information necessary to apply the methodology is sufficient for only a few investments in a few countries. Moreover, even for these cases, the estimated economic returns vary widely depending on the assumptions used. Despite these limitations, the available evidence suggests that some types of investments in youth, e.g., investments in formal schooling, adult basic education and literacy, some types of school-based health investments (e.g., micronutrient supplements and, under certain circumstances, reproductive health programs), and measures designed to reduce the consumption of tobacco (e.g., increases in the tobacco tax), yield economic returns that are at least as high as are those for many investments in other sectors. The lack of reliable information on the effects of many investments in youth is the most important information gap and the area meriting the highest priority for future research.

56 Scaling Up AIDS Treatment in Developing Countries: A Review of Current and Future Arguments. Until recently, antiretroviral treatment against AIDS was perceived to be beyond the reach of the majority of patients in developing countries. This situation has changed drastically as international funding for AIDS treatment has swelled to several billion dollars a year. What has brought about this change? Analysis of the merit of six arguments often put forward against scaling up AIDS treatment in developing countries makes it clear that the most significant (and perhaps only) real change has been the large reduction in the price of the drugs. Although affordability is obviously a central issue, it is noticeable that most of the remaining arguments continue to be unresolved. This underlines the dangers of proceeding too fast towards treatment goals.

57 Effectiveness and safety of a generic fixed-dose combination of nevirapine, stavudine, and lamivudine in HIV-1- infected adults in Cameroon: open-label multicentre trial. Summary Background: Generic fixed-dose combinations have been prequalified by WHO to treat HIV-infected patients in resource- limited countries. Despite their widespread use they are, however, not yet recommended by some of the major donor agencies owing to scarcity of clinical data on effectiveness, safety, and quality. We aimed to assess these issues for one of the most frequently prescribed treatments in Africa, a generic fixed-dose combination of nevirapine, stavudine, and lamivudine. Methods: 60 patients were followed in an open-label, 24-week multicentre trial in Cameroon. All patients received one tablet of the fixed-dose combination drug twice daily. The primary outcome measure was the proportion of patients with viral load less than 400 copies per mL at the end of the study period, in an intention-to-treat analysis. Findings: At baseline, 92% of patients (n=55) had AIDS; median CD4 count was 118 cells per _L (IQR 78–167) and median plasma HIV-1 RNA was 104 736 copies per mL (40 804–243 787). The proportion of patients with undetectable viral load (<400 copies per mL) after 24 weeks of treatment was 80% (95% CI 68–89). Median (IQR) change in viral load was –3·1 log10 copies per mL (–2·5 to –3·6) and in CD4 count 83 cells per _L (40–178). The probability of remaining alive or free of new AIDS-defining events was 0·85 (95% CI 0·73–0·92). Frequency of disease progression was 32·0 (95% CI 16·6–61·5), severe adverse effects 17·8 (7·4–42·7), and genotypic resistance mutations 7·1 (1·8–28·4) per 100 person-years. Mean reported adherence rate was 99%. Median drug concentrations in tablets were 96% of expected values for nevirapine, 89% for stavudine, and 99% for lamivudine. Interpretation: Our findings lend support to use and funding of a generic fixed-dose combination of nevirapine, stavudine, and lamivudine as first-line antiretroviral treatment in developing countries.

58 Are we spending too much on HIV? No abstract – short communication

59 Absorptive capacity and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation Summary Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002 to attract and rapidly disburse money to fight these diseases. However, some commentators believe that poor countries cannot effectively use such resources to increase delivery of their health programmes—referred to as a lack of absorptive capacity. We aimed to investigate the major determinants of grant implementation in developing countries. Methods: With information available publicly on the Global Fund‘s website, we did random-effects analysis to investigate the effect of grant characteristics, types of primary recipient and local fund agent, and country attributes on disbursements that were made between 2003 and 2005 (phase one of Global Fund payments). To check the robustness of findings, regression results from alternative estimation methods and model specifications were also tested. Findings: Grant characteristics—such as size of commitment, lag time between signature and fi rst disbursement, and funding round—had significant effects on grant implementation. Enhanced political stability was associated with high use of grants. Low-income countries, and those with less-developed health systems for a given level of income, were more likely to have a higher rate of grant implementation than nations with higher incomes or more developed health systems. Interpretation: The higher rate of grant implementation seen in countries with low income and low health-spending lends support to proponents of major increases in health assistance for the poorest countries and argues that focusing resources on low-income nations, particularly those with political stability, will not create difficulties of absorptive capacity. Our analysis was restricted to grant implementation, which is one part of the issue of absorptive capacity. In the future, assessment of the effect of Global Fund grants on intervention coverage will be vital.

60 Global Progress in PMTCT and Paediatric HIV Care and Treatment in Low- and Middle-Income Countries in 2004– 2005. A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004–2005 from low- and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral

treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.

61 Priorities in Global Assistance for Health, AIDS, and Population. Conclusions: The gap between needs and resources in global health development is enormous, and, as a result, so is the importance of priority setting. Three questions of relevance to policymakers as they address this challenge are: What are the recent trends in development assistance for the health sector, and what do they tell us about overall priorities in health? What factors explain priorities within the health sector? And how closely do observed development assistance priorities correspond to the health priorities expressed by policymakers in poor countries? In this article I have presented findings related to these questions. The short answer to the first question is that HIV/AIDS is the priority. It accounts for the increased share of health in total official development assistance over the last decade. If HIV/AIDS is excluded from the calculation, health has actually declined as a share of development assistance, from 5.4 percent in 1993 to 5.0 percent in 2003. Within the health, AIDS, and population sector, apart from HIV/AIDS only infectious disease control has seen an increased share of resources. It is possible that the rising share of infectious disease control, a classic public good, reflects growing reliance on the global public good rationale for international assistance, but other explanations cannot be excluded. Basic health care and infrastructure, health education and personnel development, reproductive health and family planning, and basic nutrition—all pro-poor interventions—have experienced declining shares. Taken together, pro-poor health interventions apart from HIV/AIDS have seen their share of health assistance drop from 57.2 percent to 42.0 percent and their share of total development assistance resources drop from 3.1 percent to 2.8 percent. These trends apply not only to aid-recipient countries as a whole, but to the subset of least-income countries. The observed declines in share are consistent neither with the current emphasis on health as a priority sector in development, as evidenced by the prominence of health concerns in the Millennium Development Goals, nor with growing awareness of links between health and poverty. The declines lend strength to concerns, voiced by groups such as the WHO Commission on Macroeconomics and Health, regarding the insufficiency of international support for health. They also raise issues about how effectively health assistance is addressing the needs of the poor. Finally, concentrating assistance on HIV/AIDS, however laudable the intent, carries with it the danger of lopsided, distorted health-sector development. The answer to the second question is that the most commonly cited prioritization tool, the burden of disease as measured in disability-adjusted life years, is insufficient to explain observed priorities. Previous research on infectious diseases has concluded that factors apart from the burden of disease play a role in determining how development assistance is allocated. Such factors, it has been argued, include the existence of cost-effective interventions, the characteristics of the victims, the presence of a global advocacy community, the inability of countries to cope on their own, and the possibility of catastrophic national and international consequences if remedial steps are not taken. I have extended and strengthened these assertions by concluding that they apply to all disease categories, not just infectious diseases. HIV/AIDS stands out for the large allocation of resources it receives relative to its contribution to the total burden of disease; so too, though less dramatically, does reproductive and maternal health. Disease categories receiving less support than might be expected on the basis of their contribution to the burden of disease are injuries and nutritional disorders. These results suggest the need for efforts to devise explicit priority-setting frameworks in which the burden of disease is only one factor among many. Ongoing work by the Global Forum for Health Research (2004) provides a model for such approaches, although this work is limited to priority setting in health research and development. In making a first systematic attempt to compare aid allocations to low-income countries‘ health priorities as expressed in their poverty-reduction strategies, I have arrived at an ambiguous answer to the third question, namely, if development assistance allocations and country priorities do correspond, the correspondence is not plainly evident. I detected no clear relationship between priorities expressed in poverty-reduction strategies and the composition of development assistance. Methodological problems may be to blame—for example, the index I have devised may not measure priorities per se but rather how well these priorities have been translated into the framework of poverty-reduction strategies. In this case, however, I would expect the index to be related to the share of development assistance allocated to general health policy, administration, and management. I found only slim evidence of this relationship. Whatever the explanation, I conclude that the absence of a clear relationship between how health is treated in the preparation of poverty-reduction strategies and the composition of development assistance should signal to policymakers that there is room for improvement in the process of preparing such strategies, in the allocation of development assistance, or both.

62 Interventions to prevent HIV/AIDS among adolescents in less developed countries: are they effective? Abstract cannot be copied & Full text not available

63 An overview of HIV/AIDS workplace policies and programmes in southern Africa. Abstract Background: Workplace programmes refer to a range of company-based interventions including the institution of an HIV/AIDS policy, voluntary counselling and testing (VCT), and antiretroviral therapy (ART) provision. Objective: To review the existing information on workplace policies and programmes in southern Africa, and ascertain the common accomplishments in and challenges to implementation and efficacy. Methods: Given the paucity of peer-reviewed academic publications, information for this review was also drawn from working papers, symposia proceedings, and case studies. A convenience sample of 17 key informants was identified, and semi-structured interviews were conducted. Results: Workplace policies and programmes of varying sophistication are proliferating in large companies and selected sectors. Accomplishments include the institution of a legal apparatus that safeguards against discriminatory practices, the high prevalence of HIV education programmes, the growing provision of VCT, and the development of supply-chain initiatives that may enable smaller companies to develop HIV programmes. Challenges include poor recognition and monitoring of legal violations by management and unions, lack of monitoring and evaluation (M&E) methodologies for workplace HIV prevention programmes, persistent stigma in the workplace resulting in poor uptake of HIV testing, and low enrollment into workplace ART programmes. Conclusion: The existing literature indicates a wide variation in workplace policies and programmes currently in place in southern Africa. The effectiveness of workplace interventions at the firm level, including prevention and treatment programmes is difficult to assess with currently available data. Further research on workplace programmes that addresses operational challenges to implementation and develops M&E strategies is urgently needed.

64 Pharmacotherapy Issues, Challenges, and Priorities in sub-Saharan African Countries. The use of potent antiretroviral drugs has led to successful treatment of HIV infection in most high-income countries. However, therapy remains largely unaffordable to the resource-limited world, particularly to countries in sub-Saharan Africa. The disparity and subsequent disease burden are devastating to the poorly resourced countries, hence creating a greater demand for international collaboration. This review outlines key examples of emerging HIV pharmacotherapy issues, challenges, and priorities within resourcelimited settings in order to lay groundwork for potential enhancement of international research collaboration efforts. The prevalence and distribution patterns of HIV infection and sociocultural factors found in sub-Saharan African settings are discussed. Challenges include drug fi nancing, drug distribution infrastructure, and government commitment to responding to the HIV pandemic. Priorities include prevention of HIV transmission, management of pediatric patients, availability of affordable medicines, and addressing concerns over the quality of medicines. The potential for effective international collaboration is enhanced when expertise and resources from the developed world are combined with an understanding of the uniquepriorities of resource-limited settings.

65 Assessing the Efficiency of HIV Prevention around the World: Methods of the PANCEA Project Objective. To develop data collection methods suitable to obtain data to assess the costs, cost-efficiency, and cost- effectiveness of eight types of HIV prevention programs in five countries. Data Sources/Study Setting. Primary data collection from prevention programs for 2002–2003 and prior years, in Uganda, South Africa, India, Mexico, and Russia. Study Design. This study consisted of a retrospective review of HIV prevention programs covering one to several years of data. Key variables include services delivered (outputs), quality indicators, and costs. Data Collection/Extraction Methods. Data were collected by trained in-country teams during week-long site visits, by reviewing service and financial records and interviewing program managers and clients. Principal Findings. Preliminary data suggest that the unit cost of HIV prevention programs may be both higher and more variable than previous studies suggest. Conclusions. A mix of standard data collection methods can be successfully implemented across different HIV prevention program types and countries. These methods can provide comprehensive services and cost data, which may carry valuable information for the allocation of HIV prevention resources.

66 Mass orphanhood in the era of HIV/AIDS. No abstract - Short article

67 Microbicides in HIV prevention In 1999 about 5.4 million people were newly infected with HIV.1 In some countries public health programmes have achieved modest gains in reducing HIV transmission through behavioural change, but the worldwide picture is one of increasing rates of infection. Although the use of condoms has slowly increased in countries most severely affected by the HIV epidemic, many vulnerable women are unable to ensure they are used. An effective and affordable vaginal microbicide, whose use

could be controlled by women, would represent an important addition to the armamentarium against HIV infection. In this article we examine current progress in microbicide development and discuss their future role in HIV control.

68 HIV Vaccines Abstract: A prophylactic vaccine for HIV-1 is badly needed. Despite 20 years of effort, it is still a long way off. However, considerable progress has been made in understanding the problem. The virus envelope has evolved to evade neutralizing antibodies in an extraordinary way, yet a vaccine that can stimulate such antibodies remains the best hope. Anti-HIV-1 T cell responses are evaded by continuous mutation of the virus. Vaccine strategies that concentrate on stimulating T cell immunity will at best generate broadly reactive and persisting T cell responses that can suppress virus without preventing infection, limiting or preventing the damage the virus causes. The SIV macaque models give encouragement that this is possible, but they need further understanding. Therapeutic vaccination should also be considered. Full text missing

69 Developing an evidence-based, preventive care package for persons with HIV in Africa Currently, 95% of the 40 million persons with HIV live in low and middle income countries; 27 million in sub-Saharan Africa. HIV/AIDS is a leading cause of death in the region, yet access to care and treatment considered standard-of-care in the industrialized world is extremely limited. There is a need for standardized, evidence-based recommendations on preventive measures. We developed a list of potential interventions based, when possible, on documented efficacy in reducing morbidity or mortality among persons with HIV in Africa. We considered the accessibility, affordability, and potential for implementation using existing health care infrastructure. Potential components included cotrimoxazole prophylaxis, safe drinking water, isoniazid prophylaxis, insecticide-treated bed nets, micronutrients, and provision of HIV counseling and testing and condoms to family members of persons with HIV. There are several additional interventions for which further evaluation would be useful before inclusion in a standard package of care, including acyclovir prophylaxis, food supplementation, hand washing, and fluconazole prophylaxis. The provision of a basic care package could be an important step toward reducing health care disparities and gaining more control of the global HIV/AIDS epidemic.

70 Challenge Paper on Communicable Diseases – Ch.4 control of HIV/AIDS. Executive Summary: Control of HIV/AIDS The HIV/AIDS pandemic is devastating the economies of many low- and middleincome countries. Current estimates are that more than 22m people have already died, 34-46m are currently living with HIV/AIDS, and 5.3m new infections occur each year. The scale of the problem is such that it is considered a development issue and global security threat. The costs and benefits of approaches to addressing the epidemic were estimated, drawing on four different sources of information: a macroeconomic model of the gains to prevention in several north African and Middle Eastern countries at the ‗nascent‘ stage of the epidemic; the costs and benefits of successful control in Thailand, at the ‗concentrated‘ stage of the epidemic; evidence on the cost-effectiveness of a number of specific interventions in Africa; and estimates of the cost and health impact of the UNGASS global programme. For the group of North African/Middle Eastern countries, intervening now was estimated to save 15-30% of 2000 GNP by 2005. In Thailand, the ANB of the AIDS control was Int$3.5 bn and BCR 15. BCRs of individual interventions were highly variable but generally exceeded 2, with condom distribution and blood safety having BCRs of 466. The UNGASS package had ANB of Int$359.4 bn and BCR of 50.

71 A meta-evaluation, or quality assessment, of the evaluations in this issue, based on the African Evaluation Guidelines: 2002. Fourteen evaluations of UNICEF and UNAIDS HIV/AIDS programmes underwent a quality control process called ‗meta- evaluation‘, which is an evaluation of the quality of the evaluation. This process of evaluating an evaluation is considered professional good practice by African Evaluation Associations and Networks, as well as the American, Canadian, German, Korean, Swiss and other national professional associations of evaluators. The quality control criteria used were the African Evaluation Guidelines—a list of 30 quality-enhancing standards that can be used as a checklist by evaluators to ensure that evaluation studies are performed well. These quality control criteria can also be applied retrospectively as a quality control method, to assess completed evaluation studies. The results of this quality control review process, for the 14 papers in this issue of Evaluation and Program Planning, are presented and discussed. An indication of a possible area of weakness in HIV/AIDS programme evaluation emerges from this analysis.

72 Simplified Regimens for Treating HIV Infection and AIDS

Purpose:To review the variables that greatly affect adherence to the complex treatment regimens used in HIV disease and to examine available options that could improve patient outcomes. Data Sources: Comprehensive review of current medical and scientific literature, drug-prescribing literature, and randomized clinical trials of drug treatments. Conclusions: Effective treatment of HIV infection is dependent on consistent adherence to prescribed antiretroviral medications. A large pill burden, multiple daily doses, and adverse events are some of the complexities that negatively impact patient adherence. For example, lipodystrophy and hyperlipidemia are two serious side effects associated with some agents. Once-daily antiretroviral agents offer many advantages over historical treatment options but are associated with possible drawbacks. Implications for Practice: Currently, four single agents are available for once-daily administration, and a few others are under investigation. In addition, combination therapy with either dual or boosted protease inhibitor regimens is becoming a popular way of overcoming the poor pharmacokinetic characteristics of individual protease inhibitors.

73 Assessing HIV resistance in developing countries: Brazil as a case study. Abstract: Increased transmission of resistant HIV has been raised as a potential consequence of expanded access to antiretroviral therapy. We review how limitations in resources and health care infrastructure may impact the transmission of resistant HIV, and we examine data from Brazil as a case study. We introduce a biological and clinical framework to identify the major determinants of transmitted resistance and to discuss how these determinants may be affected by a lack of infrastructure. We then use our framework to examine HIV resistance data from Brazil. This country was chosen as a case study due to its extensive experience delivering antiretroviral drugs and because of the availability of data on the prevalence of resistant HIV there. The data from Brazil show that antiretroviral therapy can be delivered in a resource-limited setting without resulting in widespread transmission of resistant virus. While the Brazilian experience does not necessarily generalize to countries with less health care infrastructure, neither theory nor data support a foregone conclusion that resistance will necessarily dominate HIV epidemics in the developing world to a greater extent than it does in the developed world.

74 The Global Fund to fight Aids, Tuberculosis and Malaria (GFATM) Short opinion piece

75 Global Fund grant programmes: an analysis of evaluation scores Summary Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria evaluates programme performance after 2 years to help decide whether to continue funding. We aimed to identify the correlation between programme evaluation scores and characteristics of the programme, the health sector, and the recipient country. Methods: We obtained data on the first 140 Global Fund grants evaluated in 2006, and analysed 134 of these. We used an ordered probit multivariate analysis to link evaluation scores to different characteristics, allowing us to record the association between changes in those characteristics and the probability of a programme receiving a particular evaluation score. Findings: Programmes that had government agencies as principal recipients, had a large amount of funding, were focused on malaria, had weak initial proposals, or were evaluated by the accounting firm KPMG, scored lowest. Countries with a high number of doctors per head, high measles immunisation rates, few health-sector donors, and high disease-prevalence rates had higher evaluation scores. Poor countries, those with small government budget deficits, and those that have or have had socialist governments also received higher scores. Interpretation: Our results show associations, not causality, and they focus on evaluation scores rather than actual performance of the programmes. Yet they provide some early indications of characteristics that can help the Global Fund identify and monitor programmes that might be at risk. The results should not be used to influence the distribution of funding, but rather to allocate resources for oversight and risk management.

76 Monitoring and evaluation of programmes to prevent mother to child transmission of HIV in Africa Summary points: Programmes to prevent mother to child transmission of HIV are an important part of global AIDS initiatives. Data on the effectiveness of these programmes are scarce. Current indicators to monitor and evaluate the programmes are inadequate. Comprehensive indicators that monitor all stages of the prevention cascade are urgently needed.

77 Better (RED)™ than Dead: ‗Brand Aid‘, Celebrities and the New Frontier of Development Assistance. Abstract: Bono‘s launch of Product (RED)™ at Davos in 2006 marks the opening of a new frontier for development aid. The advent of ‗Brand Aid‘ explicitly linked to commerce, not philanthropy, reconfigures the modalities of international development assistance. American Express, Gap, Converse and Armani represent the faces of ethical intervention in the

world, as customers are encouraged to do good by dressing well. Consumption, trade and aid wed dying Africans with designer goods, as a new social contract is created to generate a sustainable flow of money to support The Global Fund to Fight AIDS, Tuberculosis and Malaria. Aid celebrities – the bard, the teacher and the healer – guarantee the ‗cool quotient,‘ the management and the target of this new modality. Bono is the rock-star who led his fans to believe that they could solve Africa‘s problems of AIDS and poverty. Jeffrey Sachs is the recently-radicalized economist who masterminded The Global Fund. And Paul Farmer is the physician who convinced the world that treatment of AIDS was possible in even the poorest communities. The consumer‘s signification of status through designer RED products does not represent the exploitation of the most downtrodden – it actually helps them. ‗Brand Aid‘ creates a world where it is possible to have as much as you want without depriving anyone else. Promoted as new leftist development chic, compassionate consumption effectively de-links the relations of capitalist production from AIDS and poverty.

78 Education sector responses to HIV and AIDS: Learning from good practices in Africa. Ececutive Summary’s introduction: Globally, the HIV and AIDS epidemic remains a major public health, social, economic and development challenge. The Commonwealth Heads of Government have reaffirmed their commitment to combating HIV and AIDS, malaria and other communicable diseases in recognition of the human devastation caused by HIV and AIDS and the threat it poses to sustainable development. In the Commonwealth Sierra Leone mid-term review of the 15th Conference of Commonwealth Education Ministers (CCEM) held in 2005, African education ministers expressed interest in learning about good practices regarding education sector responses to HIV and AIDS in Africa. Education is one of the sectors worst affected by the pandemic. On the one hand, HIV and AIDS have affected educator supply because of the relatively high sero-prevalence found among teachers. On the other, it has made millions of children orphans, thereby increasing the responsibility of schools and teachers. This document summarises the key issues regarding HIV and AIDS and the education sector and is based primarily on a review of published literature and the findings of the regional workshop organised by the Commonwealth Secretariat and the Association for the Development of Education in Africa (ADEA) from 12 to 14 September 2006 at the Airport Grand Hotel in Johannesburg, South Africa. The workshop was attended by 40 delegates, and its focus was on ‗Good Practices in Education Sector Responses to HIV and AIDS in Africa‘. The main aim of the workshop was to provide a forum for the sharing, presentation and review of HIV and AIDS good practice education sector responses in Africa. Speakers included technical experts and government officials, and presentations varied from overall education sector responses to specific country and programme experiences.

79 Government–NGO collaboration and sustainability of orphans and vulnerable children projects in southern Africa. Abstract: Given current donor attention to orphans and children made vulnerable by HIV/AIDS, and the need for a new framework that recognizes the complementary roles of nations and non-governmental organizations (NGOs), this analysis reviews NGO-operated community-based orphans and vulnerable children (OVC) projects in Botswana, Lesotho, Namibia, South Africa, and Swaziland. There has been a lack of attention within the field of evaluation to inter-organizational relationships, specifically those with government agencies, as a factor in sustainability. We analyzed evaluations of nine OVC projects funded by the Bristol-Myers Squibb Foundation for the influence of government–NGO collaboration on project sustainability. For eight of the nine projects, evaluations provided evidence of the importance of the government partnership for sustainability. Government collaboration was important in projects designed to help families access government grants, initiate community-based solutions, and advocate for OVC rights through legislation. Government partnerships were also critical to the sustainability of two projects involved in placing children in foster care, but these showed signs of tension with government partners. In addition to the more common factors associated with sustainability, such as organizational characteristics, donors and NGOs should concentrate on developing strong partnerships with local and national government agencies for the sustainability of their projects.

80 Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review, Background: Long-term retention of patients in Africa's rapidly expanding antiretroviral therapy (ART) programs for HIV/AIDS is essential for these programs' success but has received relatively little attention. In this paper we present a systematic review of patient retention in ART programs in sub-Saharan Africa. Methods and Findings: We searched Medline, other literature databases, conference abstracts, publications archives, and the ―gray literature‖ (project reports available online) between 2000 and 2007 for reports on the proportion of adult patients retained (i.e., remaining in care and on ART) after 6 mo or longer in sub-Saharan African, non-research ART programs, with and without donor support. Estimated retention rates at 6, 12, and 24 mo were calculated and plotted for each program. Retention was also estimated using Kaplan-Meier curves. In sensitivity analyses we considered best-case, worst-case, and midpoint scenarios for retention at 2 y; the best-case scenario assumed no further attrition beyond that reported, while the worst-case scenario assumed that attrition would continue in a linear fashion. We reviewed 32 publications reporting on 33 patient cohorts (74,192 patients, 13 countries). For all studies, the weighted average follow-up period reported was 9.9 mo,

after which 77.5% of patients were retained. Loss to follow-up and death accounted for 56% and 40% of attrition, respectively. Weighted mean retention rates as reported were 79.1%, 75.0% and 61.6 % at 6, 12, and 24 mo, respectively. Of those reporting 24 mo of follow-up, the best program retained 85% of patients and the worst retained 46%. Attrition was higher in studies with shorter reporting periods, leading to monthly weighted mean attrition rates of 3.3%/mo, 1.9%/mo, and 1.6%/month for studies reporting to 6, 12, and 24 months, respectively, and suggesting that overall patient retention may be overestimated in the published reports. In sensitivity analyses, estimated retention rates ranged from 24% in the worse case to 77% in the best case at the end of 2 y, with a plausible midpoint scenario of 50%. Conclusions:Since the inception of large-scale ART access early in this decade, ART programs in Africa have retained about 60% of their patients at the end of 2 y. Loss to follow-up is the major cause of attrition, followed by death. Better patient tracing procedures, better understanding of loss to follow-up, and earlier initiation of ART to reduce mortality are needed if retention is to be improved. Retention varies widely across programs, and programs that have achieved higher retention rates can serve as models for future improvements.

81 Coming back from the dead: living with HIV as a chronic condition in rural Africa. Scaling-up of anti-retroviral therapy (ART) in resource-poor settings has dramatically reduced mortality and morbidity for those with access, but considerable challenges remain for people who are trying to live with HIV as a manageable chronic condition. A return to ‗normal life‘ for people on ART depends on the assurance of an uninterrupted, affordable and accessible supply of medication. However, many poor people also require economic support to re-establish their livelihoods, particularly where productive and financial assets have been depleted because of long-term illness. ART programmes need to seek convergence with economic programmes that have expertise in livelihood support and promotion, and with social protection initiatives. The future for those on ART depends not only on the provision of medicine but also on economic and social support for rebuilding lives and livelihoods.

82 Integrating HIV Prevention and Treatment: From Slogans to Impact Background: Through major efforts to reduce costs and expand access to antiretroviral therapy worldwide, widespread delivery of effective treatment to people living with HIV/AIDS is now conceivable even in severely resource-constrained settings. However, the potential epidemiologic impact of treatment in the context of a broader strategy for HIV/AIDS control has not yet been examined. In this paper, we quantify the opportunities and potential risks of large-scale treatment roll-out. Methods and Findings: We used an epidemiologic model of HIV/AIDS, calibrated to sub-Saharan Africa, to investigate a range of possible positive and negative health outcomes under alternative scenarios that reflect varying implementation of prevention and treatment. In baseline projections, reflecting ‗‗business as usual,‘‘ the numbers of new infections and AIDS deaths are expected to continue rising. In two scenarios representing treatment-centered strategies, with different assumptions about the impact of treatment on transmissibility and behavior, the change in the total number of new infections through 2020 ranges from a 10% increase to a 6% reduction, while the number of AIDS deaths through 2020 declines by 9% to 13%. A prevention-centered strategy provides greater reductions in incidence (36%) and mortality reductions similar to those of the treatment-centered scenarios by 2020, but more modest mortality benefits over the next 5 to 10 years. If treatment enhances prevention in a combined response, the expected benefits are substantial—29 million averted infections (55%) and 10 million averted deaths (27%) through the year 2020. However, if a narrow focus on treatment scale-up leads to reduced effectiveness of prevention efforts, the benefits of a combined response are considerably smaller—9 million averted infections (17%) and 6 million averted deaths (16%). Combining treatment with effective prevention efforts could reduce the resource needs for treatment dramatically in the long term. In the various scenarios the numbers of people being treated in 2020 ranges from 9.2 million in a treatment-only scenario with mixed effects, to 4.2 million in a combined response scenario with positive treatment–prevention synergies. Conclusions: These analyses demonstrate the importance of integrating expanded care activities with prevention activities if there are to be long-term reductions in the number of new HIV infections and significant declines in AIDS mortality. Treatment can enable more effective prevention, and prevention makes treatment affordable. Sustained progress in the global fight against HIV/AIDS will be attained only through a comprehensive response.

83 Population-based interventions for reducing sexually transmitted infections, including HIV infection. BACKGROUND: Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1999, 340 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 95% of the 40 million people infected with HIV by December 1999 live in developing countries (UNAIDS 2003). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs and HIV infection (Cameron 1989, Laga 1993). There is biological evidence, too, that the presence of an STI increases shedding of HIV, and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention.

OBJECTIVES: To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management. SEARCH STRATEGY: The following electronic databases were searched for relevant randomised trials or reviews:1) MEDLINE for the years 1966 to 2003 using the search terms "sexually transmitted diseases" and "human immunodeficiency virus infection"2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register, in the most recent issue of the Cochrane Library3) The specialist registry of trials maintained by the Cochrane Infectious Diseases Group.4) EMBASE The abstracts of relevant conferences were searched, and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate. SELECTION CRITERIA: Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers, with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up, using standard guidelines of the Cochrane Infectious Diseases Group. MAIN RESULTS: Five trials were included.Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs, the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. In the newest trial by Kamali et al, the rate ratio of behavioral intervention & STI management compared to control on HIV incidence was 1.00 (0.63-1.58, p=.98). These are consistent with Rakai data showing no effect of intervention.Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted re7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). In Kamali et al, there was a significant decrease in gonorrhoea and active syphilis cases. Rate ratio for gonorrhoea was 0.29(0.12-0.71, p=0.016), active syphilis was 0.53(0.33-0.84,p=0.016). There was a trend towards significance with intervention on the use of condoms with the last casual partner; the rate ratio was 1.27(1.02-1.56,p=0.036).Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p<0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p<0.005). There were no significant differences in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment-seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials. REVIEWERS' CONCLUSIONS: There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. The addition of the Kamali trial to the existing evidence supports the data from the Rakai trial of no effect. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. The Kamali trial shows an increase in the use of condoms, a marker for improved risk behaviors. Further community-based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints. OBS: Main report not included in file, as it was damaged.

84 Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections. Summary: During the past year, a group has argued that unsafe injections are a major if not the main mode of HIV-1 transmission in sub-Saharan Africa. We review the main arguments used to question the epidemiological interpretations on

the lead role of unsafe sex in HIV-1 transmission, and conclude there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa. Conversely, though there is a clear need to eliminate all unsafe injections, epidemiological evidence indicates that sexual transmission continues to be by far the major mode of spread of HIV-1 in the region. Increased efforts are needed to reduce sexual transmission of HIV-1.

85 Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges. Abstract: Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors‘ experience in southern Africa and the World Health Organization‘s framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management.

86 Effects of the Global Fund on Reproductive Health in Ethiopia and Malawi: Baseline Findings Abstract: This report is part of the System-wide Effects of the Fund (SWEF) research initiative, which aims to assess the effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) and the activities it supports on reproductive health and family planning programs in Ethiopia and Malawi. The main research objectives are to consider the effects of GF activities on the policy process, human resources, the public/private mix, and pharmaceutical and commodity procurement and management with relation to reproductive health and family planning services. Findings are that reproductive health players have not participated extensively in GF planning processes, and GF activities are not integrated with reproductive health, family planning, or other preventive care services. Health workers have increased responsibilities with GF activities and work in resource-constrained environments. In Ethiopia, health workers are shifting out of the public sector in search of better working conditions at non-governmental organizations (NGOs), bilateral aid agencies, and international organizations, and, in Malawi, there is evidence of resource shifts away from community health programs like reproductive health and family planning in favor of activities related to the three focal diseases of AIDS, tuberculosis, and malaria. While both public and private facilities offer reproductive services, they are available in almost all public health facilities, but in fewer private facilities. The number of private NGOs has grown, while the involvement of the private nonprofit sector remains limited. Systems for commodity procurement and disbursement have improved in Ethiopia, while fewer improvements to the system have occurred in Malawi as GF activities have been implemented. In order to bolster reproductive health and family planning services in future GF activities, reproductive health advocates and providers should make a case for integrating services for these focal diseases with reproductive health and family planning, and become more involved in the planning process for GF activities.

87 Global Fund – World Bank HIV/AIDS Programs Comparative Advantage Study. Executive Summary very long (9 pages)

88 HIV and male circumcision—a systematic review with assessment of the quality of studies: Summary: This Cochrane systematic review assesses the evidence for an interventional effect of male circumcision in preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse. The review includes a comprehensive assessment of the quality of all 37 included observational studies. Studies in high-risk populations consisted of four cohort studies, 12 cross-sectional studies, and three case-control studies; general population studies consisted of one cohort study, 16 cross-sectional studies, and one case-control study. There is evidence of methodological heterogeneity between studies, and statistical heterogeneity was highly significant for both general population cross-sectional studies (χ2=132·34; degrees of freedom [df]=15; p<0·00001) and high-risk cross-sectional studies (χ2=29·70; df=10; p=0·001). Study quality was very variable and no studies measured the same set of potential confounding variables. Therefore, conducting a meta-analysis was inappropriate. Detailed quality assessment of observational studies can provide a useful visual aid to interpreting findings. Although most studies show an association between male circumcision and prevention of HIV, these results may be limited by confounding, which is unlikely to be adjusted for.

89 System-wide Effects of the Global Fund: Interim Findings from Three Country studies. Executive Summary: This paper reports interim findings from research conducted under the auspices of the Systemwide Effects of the Fund (SWEF) research network to assess the effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) on the broader health systems in Benin, Ethiopia, and Malawi. The overarching objective of the SWEF research is to assess how GF support has interacted with the health systems of recipient countries, focusing on four thematic areas, namely the effects upon: (i) the policy environment; (ii) human resources; (iii) the public/private mix; and (iv) pharmaceuticals and commodities. Baseline data were collected through document review, key stakeholder interviews, and facility and provider surveys. Overall, the findings suggest that GF support has caused a range of different types of effects on health systems. There is some evidence of GF processes contributing to stronger health systems, while in other cases GF-supported processes have revealed long-standing systems weaknesses. Findings highlight several areas of concern, such as a disconnect between GF-related processes and existing national policies on decentralization and cost recovery; human resource constraints; and the creation of parallel systems for procurement of drugs and commodities. Examples of positive effects include the creation of new public/private partnerships, and training and infrastructure strengthening efforts that may have positive spin-off effects to other areas of the health system. The research‘s reported aim is to improve stakeholders‘ understanding of the range of possible effects that GF support may have upon health systems so that negative effects can be ameliorated and positive effects reinforced. Several recommendations are highlighted that stakeholders – including the GF and the broader international development community – should consider to improve opportunities for beneficial effects upon broader health systems. The Partners for Health Reformplus will conduct follow-up SWEF surveys in the three study countries in 2005/2006, allowing for more in- depth consideration of systemwide changes related to the influx of resources from the GF.

90 Systematic review of the efficacy of antiretroviral therapies for reducing the risk of mother-to-child transmission of HIV infection. Summary: Objective: To evaluate the efficacy of antiretroviral therapies in reducing the risk of mother-to-child transmission of HIV infection. Methods: Systematic review and meta-analysis of randomized controlled trials. Clinical trials of antiretrovirals were identified through electronic searches (MEDLINE, EMBASE, BIOSIS, EBM review and the Cochrane Library) up until November 2006. Historical searches of reference lists of relevant randomized controlled trials, and systematic and narrative reviews were also undertaken. Studies were included if they were (i) randomized controlled trials of any antiretroviral therapy aimed at decreasing the risk of mother-to-child transmission of HIV infection, (ii) reporting outcomes in terms of HIV infection in infant, infant death, stillbirth, premature delivery, or low birth weight. The data were extracted by a single investigator and checked by a second investigator. Disagreements were resolved through discussion or a third investigator. The efficacy was estimated using relative risk (RR), risk difference (RD) and number needed to treat (NNT) together with 95% confidence intervals. Results: Fifteen trials were included in the systematic review.Based on five placebo-controlled trials, a zidovudine regimen reduced the risk of mother-to-child transmission by 43% (95% CI: 29–55%).The incidence of low birth-weight seems to be decreased with zidovudine (pooled RR 0Æ75, 95% CI: 0Æ57–0Æ99). The efficacy of short-short course of zidovudine was comparable with that of the long short course. Nevirapine monotherapy given to mothers and babies as a single-dose reduced the risk of vertical transmission compared with an intra-partum and post-partum regimen of zidovudine (RR 0Æ60, 95% CI: 0Æ41–0Æ87). Zidovudine plus lamivudine was effective in reducing the risk of maternal-child transmission of HIV (RR 0Æ63, 95% CI: 0Æ45–0Æ90). Adding zidovudine to single-dose nevirapine in babies was no more effective than nevirapine alone (pooled RR 0Æ88, 95% CI: 0Æ47–1Æ63), nor was there any significant differencebetween zidovudine plus lamivudine and nevirapine. In mothers who were treated with standard antiretroviral therapy, no additional benefit was observed with the addition of a single dose of nevirapine in mothers and newborns. In addition, for mothers who received zidovudine prophylaxis, a two-dose intrapartum/newborn nevirapine reduced the risk of HIVinfection and death of babies by 68% (95% CI: 39–83%) and 80%(95%CI: 10–95%), respectively, when compared with placebo. Conclusions: The available evidence suggests that zidovudine alone or in combination with lamivudine and nevirapine monotherapy is effective for the prevention of mother-to-child transmission of HIV. They may also be beneficial in reducing the risk of infant death. Different antiretroviral regimens appear to be comparably effective in reducing HIV transmission from mothers to babies. In mothers already receiving zidovudine prophylaxis, adding a single dose of nevirapine to mothers during labour and giving the same drug to infants may further decrease the risk of vertical transmission and infant death.

91 Global plagues and the Global Fund: Challenges in the fight against HIV, TB and malaria. Abstract Background: Although a grossly disproportionate burden of disease from HIV/AIDS, TB and

malaria remains in the Global South, these infectious diseases have finally risen to the top of the international agenda in recent years. Ideal strategies for combating these diseases must balance the advantages and disadvantages of 'vertical' disease control programs and ―horizontal' capacitybuilding approaches. Discussion: The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) represents an important step forward in the struggle against these pathogens. While its goals are laudable,significant barriers persist. Most significant is the pitiful lack of funds committed by world governments, particularly those of the very G8 countries whose discussions gave rise to the Fund. A drastic scaling up of resources is the first clear requirement for the GFATM to live up to the international community's lofty intentions. A directly related issue is that of maintaining a strong commitment to the treatment of the three diseases along with traditional prevention approaches, with the ensuing debates over providing affordable access to medications in the face of the pharmaceutical industry's vigorous protection of patent rights. Summary: At this early point in the Fund's history, it remains to be seen how these issues will be resolved at the programming level. Nevertheless, it is clear that significant structural changes are required in such domains as global spending priorities, debt relief, trade policy, and corporate responsibility. HIV/AIDS, tuberculosis and malaria are global problems borne of gross socioeconomic inequality, and their solutions require correspondingly geopolitical solutions.

92 The Costs of Treating Curable Sexually Transmitted Infections in Low- and Middle-Income Countries: A Systematic Review. Background: Calls for increased investment in sexually transmitted infection (STI) treatment across the developing world have been made to address the high disease burden and the association with HIV transmission. Goals: The goals of this study were to systematically review evidence on the cost of treating curable STIs and to explore its key determinants. Study: A search of published literature was conducted in PubMed and supplemented by reviews of gray literature. Studies were analyzed by broad focus. Regression analysis explored how intervention characteristics affect unit costs, accounting for differences in costing methods. Results: Fifty-three primary studies were identified, of which 62% used empirical data, 35% presented economic costs, and 22% presented full costs. The median STI treatment cost was $17.80. Clinics serving symptomatic patients were consistently cheaper than outreach services, services using syndromic management protocols had lower costs, and unit costs decreased with scale. Conclusions: The compiled cost data provide an evidence base that can be used to help inform resource planning.

93 The Economic Impact of AIDS Treatment: Labor Supply in Western Kenya. Using longitudinal survey data from western Kenya, this paper estimates the economic impacts of antiretroviral treatment. The responses in two important outcomes are studied: (1) labor supply of adult AIDS patients receiving treatment; and (2) labor supply of patients‘ household members. We find that within six months after treatment initiation, there is a 20 percent increase in patients‘ likelihood of participating in the labor force and a 35 percent increase in weekly hours worked. Since patient health would continue to decline without treatment, these labor supply responses are underestimates of the impact of treatment on the treated. The upper bound of the treatment impact, based on plausible assumptions about the counterfactual, is considerably larger. The responses in household members‘ labor supply are heterogeneous, with young boys and women working significantly less after initiation of treatment. The effects on child labor are important since they suggest potential schooling impacts from treatment.

94 Women and HIV/AIDS: Confronting the Crisis. Preface: HIV/AIDS is no longer striking primarily men. Today, more than 20 years into the epidemic, women account for nearly half the 40 million people living with HIV worldwide. In sub-Saharan Africa, 57 per cent of adults with HIV are women, and young women aged 15 to 24 are more than three times as likely to be infected as young men. Despite this alarming trend, women know less than men about how HIV/AIDS is transmitted and how to prevent infection, and what little they do know is often rendered useless by the discrimination and violence they face. This report is an urgent call to action to address the triple threat of gender inequality, poverty and HIV/AIDS. By tackling these forces simultaneously, we can reduce the spread of the epidemic and its devastating consequences. Women must not be regarded as victims. They are, in many places, leading the way forward. In communities scattered around the globe, women and men are taking action to increase knowledge about the disease, expand access to sexual and reproductive health and educational services, increase women‘s ability to negotiate safer sexual relations, combat gender discrimination and violence and increase access to female-controlled prevention methods such as the female condom. All of these efforts, outlined in this report, are critical. As long as women and adolescent girls are unable to earn an income and exercise their rights to education, health and property, or are threatened with violence, progress on the AIDS front will pass them by. As the stories in this report attest, there is no limit to innovative practices. Strategies for survival are pioneered every day on the ground by women living with HIV/AIDS. The limitations lie elsewhere: in the painful shortage of resources—especially for women and women‘s issues–– and in the shameful lack of political will to meet international commitments. For too many years, the voices and demands of women, particularly women living with HIV, have fallen on deaf ears. The world can no longer afford to ignore them. We

must find the money needed for care and treatment for all. We must put an end to the stigma and discrimination that limit women‘s access to treatment and leave them responsible for taking care of the ill and dying. We must make it possible for them to envision a future. This report grows out of our shared belief that the world must respond to the HIV crisis confronting women. It highlights the work of the Global Coalition on Women and AIDS—a UNAIDS initiative that supports and energizes programmes that mitigate the impact of AIDS on girls and women worldwide. Through its advocacy and networking, the Coalition is drawing greater attention to the effects of HIV on women and stimulating concrete, effective action by an ever-increasing range of partners. We believe this report, with its straightforward analysis and practical responses, can be a valuable advocacy and policy tool for addressing this complex challenge. The call to empower women has never been more urgent. We must act now to strengthen their capacity, resilience and leadership.

95 Estimating the resource needs of scaling-up HIV/AIDS and tuberculosis interventions in sub-Saharan Africa: A systematic review for national policy makers and planners Abstract: Considerable effort has been made to estimate the global resource requirements of scaling-up HIV/AIDS and tuberculosis (TB) interventions. There are currently several medium- and long-term global estimates available. Comprehensive country specific estimates are now urgently needed to ensure the successful scaling-up of these services. This paper reviews evidence on the global resource requirements of scaling-up HIV/AIDS and TB interventions. The purpose of this review is to summarise and critically appraise the methods used in the global estimates and to identify remaining knowledge gaps, particularly those relevant to country level estimation. This review found that the estimates of global resource requirements provide sound methodological guidance for countries on the basic steps to follow. However, there are still many areas that require further development or evidence. These include the following. Firstly, the methods used to assess the capacity to scale up HIV/AIDS and TB services need to be further refined. In particular countries need simple methods to assess human resource capacity. Secondly, investments need to be made to improve country level data on the costs and effectiveness of HIV/AIDS and TB services. In particular efforts should be focused on producing standardised unit costs for each intervention by country, which reflect the reality of domestic resource use. Thirdly, simple costing models, which appropriately integrate systems costs need to be developed for use at the country level. Finally, resources needs estimation needs to be embedded by countries in multi-sectoral expenditure planning processes. Countries and global agencies will continue to need estimates for different purposes at different times. Therefore attention should move away from specific estimates, to the longer term aim of building capacity at the country level, supported by global agencies. This will be of mutual benefit. Those making national resource estimates can learn from the experience of global estimation. Concurrently, global resource estimates can build on the evidence emerging from improved national resource estimates.

96 Discordant couples HIV infection among couples in Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania. Most analyses of the determinants of HIV infection are performed at the individual level. The recent Demographic and Health Surveys which include results from HIV tests allow studying HIV infection at the level of the cohabiting couple. This paper exploits this feature of the data for Burkina Faso, Cameroon, Ghana, Kenya and Tanzania. The analysis yields two surprising findings about the dynamics of the HIV/AIDS epidemic which have important implications for policy. First, at least two-thirds of the infected couples are discordant couples, i.e. couples where only one of the two partners is infected. This implies that there is scope for prevention efforts among infected couples. Second, between 30 and 40 percent of the infected couples are couples where the female partner only is infected. This is at odds with levels of self-reported marital infidelity by females and with the common perception that unfaithful males are the main link between high risk groups and the general population. This study investigates and confirms the robustness of these findings. For example, even among couples where the woman has been in only one union for ten years or more, the fraction of couples where only the female partner is infected remains high. These results indicate that extramarital sexual activity among cohabiting women, whatever its causes, is a substantial source of vulnerability to HIV that should be, as much as male infidelity, targeted by prevention efforts. Moreover, this paper uncovers several inconsistencies between the sexual behaviors reported by male and female partners, suggesting that, as much as possible, prevention policies should rely on evidence including objectively measured HIV status.

97 Who Gets AIDS and How? The determinants of HIV infection and sexual behaviors in Burkina Faso, Cameroon, Ghana, Kenya and Tanzania. This paper analyzes the determinants of HIV infection and associated sexual behaviors using data from the first five Demographic and Health Surveys to include HIV testing for a representative sample of the adult population. Emerging from a wealth of country relevant results, four important findings can be generalized. First, married women who engage in extramarital sex are less likely to use condoms than single women when doing so. Second, having been in successive marriages

is a significant risk-factor, as evidenced by the results on HIV infection and on sexual behaviors. Contrary to prima facie evidence, education is not associated positively with HIV status. But schooling is one of the most consistent predictors of behavior and knowledge: education predicts protective behaviors like condom use, use of counseling and testing, discussion among spouses and knowledge, but it also predicts a higher level of infidelity and a lower level of abstinence. Finally, male circumcision and female genital mutilation are often associated with sexual behaviors, practices and knowledge related to AIDS. This might explain why in the analysis in the five countries there is no significant negative association between male circumcision and HIV status, despite recent evidence from a randomized control trial that male circumcision has a protective effect.

98 Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base? Many donors and countries are striving to respond to the HIV/AIDS epidemic by implementing prevention programmes. However, the resources available for providing these activities relative to needs are limited. Hence, decision-makers must choose among various types of interventions. Cost information, both measures of cost and cost-effectiveness, serves as a critical input into the processes of setting priorities and allocating resources efficiently. This paper reviews the cost and cost- effectiveness evidence base of HIV/AIDS prevention programmes in low- and middle-income countries (LMICs). None of the studies found have complete cost data for a full range of HIV/AIDS prevention programmes in any one country. However, the range of studies highlight the relative emphasis of different types of HIV/AIDS prevention strategies by region, reflecting the various modes of transmission and hence, to a certain extent, the stage of the epidemic. The costing methods applied and results obtained in this review give rise to questions of reliability, validity and transparency. First, not all of the studies report the methods used to calculate the costs, and/or do not provide all the necessary data inputs such that recalculation of the results is possible. Secondly, methods that are documented vary widely, rendering different studies, even within the same country and programme setting, largely incomparable. Finally, even with consistent and replicable measurement, the results as presented are generally not comparable because of the lack of a common outcome measure. Therefore, the extent to which the available cost and cost-effectiveness evidence base on HIV/AIDS prevention strategies can provide guidance to decision-makers is limited, and there is an urgent need for the generation of this knowledge for planning and decision- making.

99 Condom effectiveness in reducing heterosexual HIV transmission (Review) Abstract: Background: The amount of protection that condoms provide for HIV and other sexually transmitted infections is unknown. Cohort studies of sexually active HIV serodiscordant couples with follow-up of the seronegative partner, provide a situation in which a seronegative partner has known exposure to the disease and disease incidence can be estimated. When some individuals use condoms and some do not, namely some individuals use condoms 100% of the time and some never use (0%) condoms, condom effectiveness can be estimated by comparing the two incidence rates. Condom effectiveness is the proportionate reduction in disease due to the use of condoms. Objectives: The objective of this review is to estimate condom effectiveness in reducing heterosexual transmission of HIV. Search strategy: Studies were located using electronic databases (AIDSLINE, CINAHL, Embase, and MEDLINE) and hand- searched reference lists. Selection criteria: For inclusion, studies had to have: (1) data concerning sexually active HIV serodiscordant heterosexual couples, (2) a longitudinal study design, (3) HIV status determined by serology, and (4) contain condom usage information on a cohort of always (100%) or never (0%) condom users. Data collection and analysis: Studies identified through the above search strategy that met the inclusion criteria were reviewed for inclusion in the analysis. Sample sizes, number of seroconversions, and the person-years of disease-free exposure time were recorded for each cohort. If available, the direction of transmission in the cohort (male-to-female, female-to-male), date of study enrollment, source of infection in the index case, and the presence of other STDs was recorded. Duplicate reports on the same cohort and studies with incomplete or nonspecific information were excluded. HIV incidence was estimated from the cohorts of ―always‖ users and for the cohorts of ―never‖ users. Effectiveness was estimated from these two incidence estimates. Main results: Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of ―always‖ users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.: .56, 2.04] per 100 person- years. There were 10 cohorts of ―never‖ users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%. Authors’ conclusions: This review indicates that consistent use of condoms results in 80% reduction in HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse. Because the studies used in this review did not report on the ―correctness‖ of use, namely whether condoms were used correctly and perfectly for each and

every act of intercourse, effectiveness and not efficacy is estimated. Also, this estimate refers in general to the male condom and not specifically to the latex condom, since studies also tended not to specify the type of condom that was used. Thus, condom effectiveness is similar to, although lower than, that for contraception.

100 Position Statement on Condoms and HIV Prevention. No executive summary/résumé

101 Roundtable: Male Circumcision for HIV Prevention: Research Implications for Policy and Programming WHO/UNAIDS Technical Consultation 6–8 March 2007 Conclusions and Recommendations (Excerpts): No abstract or Conclusion

102 Extending HIV care in resource-limited settings. Despite the clear benefits of antiretroviral therapy (ART), only three countries in sub-Saharan Africa have achieved the "3 by 5" goal of treating at least half of the persons living with HIV/AIDS who need it. A major obstacle faced by many lower income countries is the establishment of treatment programs in rural areas where there is a scarcity of trained health care providers and infrastructure. This paper reviews published data on rural ART programs in lower income countries to identify necessary components of such a program. No clearly superior model for rural ART delivery has emerged. All programs document the need for expanded physical infrastructure, laboratory development, recruitment/training of additional health care providers, and/or the introduction of new technologies in order to effectively support the needs of ART roll-out.

103 Effect of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV: randomised controlled trial. Abstract Objectives: To investigate the impact of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV. Design: Two centre prospective double blind placebo controlled trial. Participants: Children aged ≥ 8 weeks with HIV. Interventions: Isoniazid or placebo given with co-trimoxazole either daily or three times a week. Setting: Two tertiary healthcare centres in South Africa. Main outcome measures: Mortality, incidence of tuberculosis, and adverse events. Results: Data on 263 children (median age 24.7 months) were available when the data safety monitoring board recommended discontinuing the placebo arm; 132 (50%) were taking isoniazid. Median follow-up was 5.7 (interquartile range 2.0-9.7) months. Mortality was lower in the isoniazid group than in the placebo group (11 (8%) v 21 (16%), hazard ratio 0.46, 95% confidence interval 0.22 to 0.95, P = 0.015) by intention to treat analysis. The benefit applied across Centers for Disease Control clinical categories and in all ages. The reduction in mortality was similar in children on three times a week or daily isoniazid. The incidence of tuberculosis was lower in the isoniazid group (5 cases, 3.8%) than in the placebo group (13 cases, 9.9%) (hazard ratio 0.28, 0.10 to 0.78, P = 0.005). All cases of tuberculosis confirmed by culture were in children in the placebo group. Conclusions: Prophylaxis with isoniazid has an early survival benefit and reduces incidence of tuberculosis in children with HIV. Prophylaxis may offer an effective public health intervention to reduce mortality in such children in settings with a high prevalence of tuberculosis.