Discrimination against HIV-Infected People and the Spread of HIV: Some Evidence from France

BACKGROUND: Many people living with HIV/AIDS (PLWHA) suffer from stigma and discrimination. There is an ongoing debate, however, about whether stigma, fear and discrimination actually fuel the persisting spread of HIV, or slow it down by reducing contacts between the whole population and high-risk minorities. To contribute to this debate, we analysed the relationship between perceived discrimination and unsafe sex in a large sample of French PLWHAs. METHODOLOGY/PRINCIPAL FINDINGS: In 2003, we conducted a national cross-sectional survey among a random sample of HIV-infected patients. The analysis was restricted to sexually active respondents (N = 2,136). Unsafe sex was defined as sexual intercourse without a condom with a seronegative/unknown serostatus partner during the prior 12 months. Separate analyses were performed for each transmission group (injecting drug use (IDU), homosexual contact, heterosexual contact). Overall, 24% of respondents reported experiences of discrimination in their close social environment (relatives, friends and colleagues) and 18% reported unsafe sex during the previous 12 months. Both prevalences were higher in the IDU group (32% for perceived discrimination, 23% for unsafe sex). In multivariate analyses, experience of discrimination in the close social environment was associated with an increase in unsafe sex for both PLWHAs infected through IDU and heterosexual contact (OR = 1.65 and 1.80 respectively). CONCLUSIONS: Our study clearly confirms a relationship between discrimination and unsafe sex among PLWHAs infected through either IDU or heterosexual contact. This relationship was especially strong in the heterosexual group that has become the main vector of HIV transmission in France, and who is the more likely of sexual mixing with the general population. These results seriously question the hypothesis that HIV-stigma has no effect or could even reduce the infection spread of HIV

Decision tools in health care: focus on the problem, not the solution

BACKGROUND: Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing £5 billion in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint. DISCUSSION: Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem. SUMMARY: We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same

Intracellular Pu Decorporation in Rat by Different DTPA Formulations

Cellular internalisation of DTPA appears negligible. Thus, a fast urinary excretion of Pu-DTPA is observed after treatments, but a slow excretion also occurs, explained by Pu-DTPA retention within the interstitium (2.5% of Pu-DTPA, half-life 1 week). One day after 14C-DTPA i.v., 1-2% of the activity was retained in perfused soft tissues, demonstrating its cellular internalisation, whereas blood DTPA was 0.025%. Encapsulation of DTPA has been proposed to improve its cellular internalisation, and a nearly total liver decorporation was obtained using stealth® 100 nm-liposomes. This study estimates intracellular decorporation of Pu by different DTPA formulations. First, a biokinetic study was performed after Pu-DTPA i.v., to help interpretation of decorporation data. About 99% of Pu was excreted via urines for the first 3 days, followed by residual excretion. Similar Pu activities were measured in skeleton, liver, kidneys and urine of day 7 (0.1%). These values, quite different than those measured after Pu-citrate i.v., demonstrated the great stability of Pu-DTPA, in extra and intracellular environments. When DTPA solutions were given i.v., 1 hour after Pu-citrate i.v., both fast and slow excretion (half-life 3-4 days) of Pu-DTPA were observed. The ratio between fast and slow excretions increased with DTPA dosage and, at similar dosage, this ratio was much lower after pulmonary insufflation of dry DTPA powder than after i.v.. Therefore, fast excretion depends on DTPA concentration in blood, whereas slow excretion, associated with intracellular DTPA, depends on total DTPA administered. This was confirmed after specific liver or lung contamination. Then, most of the urinary decorporation involved a slow process observed for 1 month. Moreover, half-life of slow excretion appeared to vary depending on tissues. In a last experiment, a treatment was performed 1 day before Pu-citrate i.v. (30 and 300µmol.kg-1). A decorporation similar to a standard treatment (30µmol.kg-1, i.v. at+1h) was observed for the highest dosage (~50%), whereas a 25 % decorporation was obtained for the lowest dosage. Altogether, these results underline the importance of intracellular DTPA in the decorporation process which will be discuss in terms of modelling and radioprotection