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For Snowden, the lesson from more than 50 years of such experiments — successes and failures — is that eradication is most likely to work when doctors, politicians, drugmakers, the media and citizens work together. Salus populi suprema lex , he reminds us: public health must be the highest law. He has preached that message to generations of Yale undergraduates, and repeats it in this book.

The risk is only that he is preaching to the converted.

Impact on Science and Society

An essential round-up of science news, opinion and analysis, delivered to your inbox every weekday. Advanced search. Laura Spinney Laura Spinney is a science writer based in Paris. Search for this author in: Pub Med Nature. PDF version. Illustration by Antoine Dore. Nature Briefing An essential round-up of science news, opinion and analysis, delivered to your inbox every weekday.

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Working together to end the AIDS-HIV pandemic | World Economic Forum

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Advanced Book Search Browse by Subject. Make an Offer. Find Rare Books Book Value. Sign up to receive offers and updates: Subscribe. But unlike Brookmeyer and Quinn's original formulation, Janssen et al. Janssen and coworkers used kits with altered optical densities to "watch" the progressive increase of antibodies against HIV over time, with "tuned" and "detuned" glasses. The new technique experienced a boom in the late s and early years of the 21st century, using a range of kits and applied to many different contexts in terms of human and virus populations A new technical alternative has recently emerged, the so called BED test 21, The BED test was designed as a reliable substitute for the classical STAHRS using detuned assays, yielding more precise estimates, but recent papers have documented major flaws in the new technique when applied in specific contexts It seems that chance is again challenging human creativity in the unfinished quest to find the holly grail of a perfect surveillance method using laboratory parameters.

But, as recognized by the authors themselves, the technique should be still tested in the field, in different contexts and populations, the true challenge of any surveillance approach. These strategies aimed to take into account the substantial constraints that the countries hardest hit by the epidemic were faced with when trying to mount even the most simple laboratory infrastructure, such as power shortage, lack of trained technicians, and increasing costs of equipments and reagents.

In this context, the progressive sophistication of laboratory-based surveillance remained basically restricted to cooperative research projects, but could not constitute the main alternative in terms of large and disseminated epidemics.

The AIDS Pandemic Impact on Science and Society

Since risky behaviors constitute the inescapable source of new infections, behavioral surveillance emerged as an interesting alternative to laboratory-intensive surveillance, especially for those contexts in which epidemics were relatively concentrated among a handful populations at increased risk. In generalized epidemics where heterosexual transmission affects a substantial proportion of the population, behavioral surveillance requires population-based large surveys, posing again the questions of high costs and complex logistics.

Behavioral surveillance faces major difficulties. The first of these was addressed by the definition of a comprehensive basket of indicators and the development of standardized questionnaires by major international institutions and funding agencies. Complexity arises, however, in the pressing need to make comparisons across different societies and cultures, and the need to tailor assessments to local characteristics and cultural mores.

One major paradigm shift must be mentioned here. With the decisive input from Jonathan Mann and coworkers 25 , the conceptual framework underlying the definition and use of behavioral and social indicators move beyond the straight-jacket of the classical concept of risk itself problematic in the field of infectious disease epidemiology and rather tailored to the assessment of non-communicable diseases toward the multidimensional paradigm and toolbox provided by the concept of vulnerability. From the point of view of epidemiologic methods, emphasis has been put on two other major difficulties: how to infer trends from serial cross-sectional studies and how to properly sample hidden populations.

Since the seminal paper by Ades 27 on serial seroprevalence surveys, one must be cautious while interpreting and inferring long-term trends from panels of successive cross-sectional studies. A key problem refers to the differential inclusion of infected and uninfected individuals in serosurveys that combine the assessment of sociodemographic and behavioral data with basic laboratory findings e.

In the context of generalized epidemics with limited access to antiretrovirals, differential inclusion of infected and uninfected individuals may merely reflect the effects of disease progression and death. In the same way, the dynamic character of background demographic factors e. On the other hand, in contexts with broad access to antiretroviral drugs, the opposite trend has been observed, as discussed in detail by Boily et al.

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AIDS and South Africa: The Social Expression of a Pandemic

The re-composition of high-risk networks after the introduction of highly active anti-retroviral therapy HAART may change the availability of infected partners seeking risky behaviors and reverse former protected behaviors of individuals inserted in such renewed networks. Last but not least, most populations particularly vulnerable to HIV infection are marginalized and stigmatized populations, out of the reach of regular health services. As hidden populations, such individuals are difficult to enumerate, and will often be missed by simple random samples.

In the same sense, in regular household surveys such populations are seldom reached, and once reached frequently deny behaviors that could be stigmatized by interviewers, family members or neighbors, or even criminalized, as in the case of the consumption of illicit drugs. Spatio-temporal sampling 28 and respondent-driven sampling 29 have been used for this purpose. Whereas most areas deeply affected by the epidemic still lack even the most basic resources in terms of surveillance, as well as severe limitations in their ability to provide for the care and management of patients living with AIDS, resource rich countries, almost invariably harboring concentrated epidemics, have progressively moved to new frontiers of surveillance such as the proactive surveillance of HIV resistance.

The best contemporary alternative to this divide has been the establishment of surveillance networks integrating developing and developed countries, such as the WHO-sponsored network on viral resistance Unfortunately, the achievements of such global networks have thus far fallen short of their ambitious goals, due to political and logistical difficulties, as well as due to the scarcity of funds. Despite the methodological and technical problems mentioned above, my firm position is that the worst surveillance is the absence of any surveillance.

No lack of accuracy or precision should function as a disincentive for the continuous monitoring of the epidemic worldwide, especially in the most deprived settings. My long-term experience with the analysis of secondary data with graduate students from Lusophone African countries at the National School of Public Health, Oswaldo Cruz Foundation, Brazil, has been a matter of concern with respect to the overall low quality and scarcity of reliable data.

However, it has also been a stimulus to reform and improve such national information systems. Each one of the trained students who return to their native countries and join the efforts of the local health authorities represents a prospect of change toward a more humane and balanced use of scientific progress. Get back: resistance and the new pharmacovigilance. As treatment rolls-out in Sub-Saharan Africa, complex challenges emerge, such as the monitoring of the emergence and eventual transmission of HIV resistant strains. However, such concerns should not be used to deter current initiatives to increase access.

The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic

Middle-income countries such as Brazil have shown that the forecasted "viral anarchy" need not take place, and that resistance levels similar to those observed in the US and Europe can be maintained over time, tracked by careful surveillance The time has come to reform the bases of AIDS surveillance. This reform should include a new emphasis on pharmacovigilance, concerned not only with monitoring new antiretroviral drugs launched in the world market, but also with monitoring new regimens for patients failing first-line regimens.

Pharmacovigilance should also be extended to examine the complications arising among the cohort of aging AIDS patients, who face the diseases of middle-age as well as the accumulated side effects of major anti-retroviral drugs used over long periods of time e. As HIV-infected people live longer, co-infections with other viruses and bacteria with long clinical courses become more relevant, as is currently happening with hepatitis C In the same way, the long-term maintenance of people with different comorbidities such as drug dependence poses new challenges such as the drug interactions between anti-retroviral medicines and methadone As discussed before, there are no easy solutions in the field of AIDS surveillance.

Besides the continuous challenge to redefine methods and strategies in order to deal with the complexity and dynamic character of the pandemic, a major challenge is always posed by those population most in need, living in low and middle-income countries hardly affected by AIDS and a myriad of other social and medical problems.

As treatment roll-outs, finally reaching the millions of people living in Subsaharan Africa and Southeast Asia living and dying from AIDS, new layers of complexity, such as growing secondary resistance to different anti-retroviral medicines, will be added to the already complex situation.


  1. A Walking Tour of Troy, New York (Look Up, America!).
  2. Science, Power and Policy Intersecting at the HIV/AIDS Pandemic;
  3. Working together to end the AIDS-HIV pandemic.

Much has been achieved by middle-income countries such as Brazil in its efforts to provide universal treatment and to establish a comprehensive system of monitoring and evaluation. The challenges ahead will require from researchers, health professionals, activists and policy makers the best of their talents and commitment, but the pandemic never gave to anyone really committed to curb it a single moment of solace.

So, it's time to renew the energies of professionals and the civil society at large, and to train a new generation of researchers and health professionals, the ones who will seek the renewed alternatives for the renewed problems posed by the time to come. Thanks are due to Cecilia Minayo for the kind invitation to write this paper, to Maya Petersen for her insightful comments and invaluable help, and to the anonymous reviewer who raised important topics I tried to incorporate in the revised version of the manuscript.

AIDS : O rastro da tormenta. Revista USP ; An African HIV-1 sequence from and implications for the origin of the epidemic. Nature ; Bastos FI. Rio de Janeiro: Fiocruz; Haile M.

Weather patterns, food security and humanitarian response in sub-Saharan Africa. Adult mortality and erosion of household viability in AIDS-afflicted towns, estates, and villages in eastern Zimbabwe. J Acquir Immune Defic Syndr. Drug surveillance and adverse reactions to drugs.