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Sometimes we deliberately build an issue around a theme; sometimes a theme just emerges. Some craft went into the cluster of articles that we have in this week's issue on HIV, but mostly it just happened.
The part that just happened is in the news—and is mostly gloomy. In his speech on HIV to the UN general assembly the UN secretary general points out that the numbers of people with the disease are still rising: 40 million people are living with HIV world wide; 8000 die and 12 000 become infected every day; and for every person who starts treatment with antiretrovirals another six become infected (doi: 10.1136/bmj.39226.442650.DB). Although the numbers of people getting antiretroviral drugs is increasing, Médicins Sans Frontières says that in parts of southern Africa there are simply too few health workers to deliver the drugs to those who need them (doi: 10.1136/bmj.39227.656481.DB). Its report blames poor salaries and conditions in the public sector, conditions that are sometimes enforced by the International Monetary Fund's caps on public spending. Another news story quotes a leading AIDS researcher as saying that an effective vaccine against HIV is unlikely in the near future because of the enormous variation among HIV viruses (doi: 10.1136/bmj.39227.629803.DB).
The part that we planned was the article and editorial on evaluating the effectiveness of HIV prevention programmes. When governments, aid agencies, and charitable foundations started promising large sums to help prevent and treat HIV infection, many commentators worried whether the health infrastructure in developing countries was up to the task of delivering often complex measures (BMJ 2004;329:1281, doi:10.1136/bmj.329.7477.1281). The Médicins Sans Frontières report is one sign that those fears may be being realised. Another is Reithinger and colleagues' analysis of the effectiveness of current programmes to prevent mother to child transmission of HIV in Africa (doi: 10.1136/bmj.39211.527488.94). They have looked at what's needed to administer prophylaxis (usually nevirapine) and to know it's been given, taken, and had the desired effect. Each step of this preventive cascade leaves room for failure—for example, one study in Malawi showed that only 19% of HIV positive mothers who had received antiretroviral drugs attended to have their infant tested for HIV. The authors argue that current methods and indicators for monitoring programmes are inadequate. In his accompanying editorial Ruairi Brugha discusses other barriers to making reliable judgments about the impact of prevention and treatment programmes (doi: 10.1136/bmj.39223.583773.80). The biggest may be political—the desire of politicians to be seen to be doing something and to claim credit for successes. Brugha detects, however, a greater willingness among the big agencies to cooperate and be realistic rather than claim the credit for “successes.”
More promising news (at least for those in the developed world) comes from Hiroyu Hatano and Steven G Deeks in their editorial on drug resistant HIV (doi: 10.1136/bmj.39205.386609.80). They discuss the promising results from three classes of new drugs developed for managing drug resistant virus. They suggest that 2007 might be the year we witness a dramatic shift in how chronically infected patients are managed.