Fraud detection in blockchain networks presents unique challenges due to the decentralized and<br/>pseudonymous nature of transactions. This study introduces a novel Multilayer Topology-Aware Graph<br/>Contrastive Learning (MTGCL) framework to detect fraudulent activity within the Ethereum transaction<br/>network. The proposed approach leverages node-level and topology-level representations, integrating<br/>persistent homology to capture high-order structural patterns and enhance anomaly detection. By<br/>employing adaptive graph augmentation and self-supervised contrastive learning, MTGCL effectively<br/>improves fraud detection performance. Empirical evaluations demonstrate that MTGCL outperforms<br/>existing graph contrastive learning models in classification accuracy across multiple time periods while<br/>maintaining competitive computational efficiency. The framework also exhibits scalability for large-scale<br/>blockchain analysis, achieving lower computational costs compared with other baselines methods. These<br/>findings highlight MTGCL’s potential for real-world applications, offering valuable insights for financial<br/>institutions, cryptocurrency exchanges, regulatory bodies, and blockchain analytics firms in combating<br/>fraudulent activities and enhancing anti-money laundering compliance.
The rapid development of cryptocurrencies has led to an increasing severity of money laundering activities. In recent years, leveraging graph neural networks for cryptocurrency fraud detection has yielded promising results. However, many existing methods predominantly focus on node classification, i.e., detecting individual illicit transactions, rather than uncovering behavioral pattern differences among money laundering groups. In this paper, we tackle the challenges presented by the organized, heterogeneous, and noisy nature of Bitcoin money laundering. We propose a novel subgraph-based contrastive learning algorithm for heterogeneous graphs, named Bit-CHetG, to perform money laundering group detection. Specifically, we employ predefined metapaths to construct the homogeneous subgraphs of wallet addresses and transaction records from the address-transaction heterogeneous graph, enhancing our ability to capture heterogeneity. Subsequently, we utilize graph neural networks to separately extract the topological embedding representations of transaction subgraphs and associated address representations of transaction nodes. Lastly, supervised contrastive learning is introduced to reduce the effect of noise, which pulls together the transaction subgraphs with the same class while pushing apart the subgraphs with different classes. By conducting experiments on two real-world datasets with homogeneous and heterogeneous graphs, the Micro F1 Score of our proposed Bit-CHetG is improved by at least 5% compared to others.
The number of money laundering crimes for Ethereum and the amount involved have grown exponentially in recent years. However, previous studies related to anomaly detection for Ethereum usually consider multiple types of financial crimes as a whole, ignoring the apparent differences between money laundering and other malicious activities and lacking a more granular detection targeting money laundering. In this paper, for the first time, we propose an improved graph embedding algorithm specifically for money laundering detection called GTN2vec. By mining Ethereum transaction records, the algorithm comprehensively considers the behavioral patterns of money launderers and structural information of transaction networks and can automatically extract features of money laundering addresses. Specifically, we fuse the gas price and timestamp from the transaction records into a new weight and set appropriate return and exploration parameters to modulate the sampling tendency of random walk to characterize the money laundering nodes. We construct the dataset using real Ethereum data and evaluate the effectiveness of GTN2vec on the dataset by various classifiers such as random forest. The experimental results show that GTN2vec can accurately and effectively extract money laundering account features and significantly outperform other advanced graph embedding methods.
César Sabater, Florian Hahn, Peter Andreas, Jan Ramon
In this paper we study verifiable sampling from probability distributions in the context of multi-party computation. This has various applications in randomized algorithms performed collaboratively by parties not trusting each other. One example is differentially private machine learning where noise should be drawn, typically from a Laplace or Gaussian distribution, and it is desirable that no party can bias this process. In particular, we propose algorithms to draw random numbers from uniform, Laplace, Gaussian and arbitrary probability distributions, and to verify honest execution of the protocols through zero-knowledge proofs. We propose protocols that result in one party knowing the drawn number and protocols that deliver the drawn random number as a shared secret.
Aldren Gonzales, Scott R. Smith, Prashila Dullabh, Lauren Hovey · 7 authors
The scale and severity of the opioid epidemic call for innovative, multipronged solutions. Research and development is key to accelerate the discovery and evaluation of interventions that support pain and substance use disorder management. In parallel, the use and integration of blockchain technology within research networks holds the potential to address some of the unique challenges facing opioid research. This paper discusses the applications of blockchain technology and illustrates potential ways in which it could be applied to strengthen the validity of outcomes research on the opioid epidemic. We reviewed published and gray literature to identify useful applications of blockchain, specifically those that address the challenges faced by opioid research networks and programs. We then convened a panel of experts to discuss the strengths, limitations, and feasibility of each application. Blockchain has the potential to address some of the issues surrounding health data management, including data availability, data sharing and interoperability, and privacy and security. We identified five primary applications of blockchain to opioids: clinical trials and pharmaceutical research, incentivizing data donation and behavior change, secure exchange and management of e-prescriptions, supply chain management, and secondary use of clinical data for research and public health surveillance. The published literature was limited, leading us to rely on gray literature, which was also limited in its discussion of the technical aspects of implementation. The technical expert panel provided additional context and an assessment of feasibility that was lacking in the literature. Research on opioid use and misuse is challenging because of disparate data stored across different systems, data and system interoperability issues, and legal requirements. These areas must be navigated to make data accessible, timely, and useful to researchers. Blockchain technologies have the potential to act as a facilitator in this process, offering a more efficient, secure, and privacy-preserving solution for data exchange. Among the 5 primary applications, we found that clinical trial research, supply chain management, and secondary use of data had the most examples in practice and the potential effectiveness of blockchain. More discussions and studies should focus on addressing technical questions concerning scalability and tackling practical concerns such as cost, standards, and governance around the implementation of blockchain in health care. Policy concerns related to balancing the need for data accessibility that also protects patient privacy and autonomy in revoking consent should also be examined.
Ha Nguyen Thi Thu, Ha Nguyen Thi Thu, Anh Quynh Nguyen, Phuong Nguyen · 7 authors
Objectives: To examine the financing trend for HIV/AIDS programme for 2011–2019 and to explore the potential options to fill funding gap and sustain the programme.Methods: Using mixed methods, including literature review and qualitative interview (16 in-depth interviews with key informants from the Ministry of Health, Ministry of Planning and Investment, Vietnam Authority of HIV/AIDS Control and related departments of Bac Ninh and Dien Bien Provinces).Results: The total fund for 2011–2019 was 22,243 billion VND (USD317.3 million) with the largest contribution of external funding (67%). The share of government budget remains quite low (9%). HIV/AIDS programme is focusing on shifting the finance of HIV/AIDS services from programme/projects to the health insurance fund; increasing the contribution of local government budget and diversifying other domestic sources. It is important for the programme to promote the integration of HIV/AIDS services into the current healthcare system and decentralization of HIV/AIDS services into primary healthcare facilities.Conclusion: To fill the funding gap for HIV/AIDS programme, it requires increasing contribution from local goverment budget for prevention activies as well as social health insurance for treatment. Lessons learnt from HIV/AIDS programme could suggest for other priority public health programmes to sustain their achievements in the upcoming years.
Bitcoin is by far the most popular crypto-currency solution enabling peer-to-peer payments. Despite some studies highlighting the network does not provide full anonymity, it is still being heavily used for a wide variety of dubious financial activities such as money laundering, ponzi schemes, and ransom-ware payments. In this paper, we explore the landscape of potential money laundering activities occurring across the Bitcoin network. Using data collected over three years, we create transaction graphs and provide an in-depth analysis on various graph characteristics to differentiate money laundering transactions from regular transactions. We found that the main difference between laundering and regular transactions lies in their output values and neighbourhood information. Then, we propose and evaluate a set of classifiers based on four types of graph features: immediate neighbours, curated features, deepwalk embeddings, and node2vec embeddings to classify money laundering and regular transactions. Results show that the node2vec-based classifier outperforms other classifiers in binary classification reaching an average accuracy of 92.29% and an F1-measure of 0.93 and high robustness over a 2.5-year time span. Finally, we demonstrate how effective our classifiers are in discovering unknown laundering services. The classifier performance dropped compared to binary classification, however, the prediction can be improved with simple ensemble techniques for some services.
Bitcoin, the world’s first cryptocurrency, was first introduced in 2009, by Satoshi Nakamoto. While many believe the name is a pseudonym, and the true identity of the creator(s) is unknown, it is an undisputed fact that cryptocurrencies have introduced an indelible change to monies worldwide. Consequently, cryptocurrencies have also introduced a plethora of new opportunities for money laundering activity.\nWhile cryptocurrencies follow the same three-step laundering process of placement, layering, and integration, the activity can be more difficult to detect due to the anonymous nature of cryptocurrencies. Moreover, while traditional schemes such as smurfing or gambling at a casino are still used as laundering techniques, more advanced methods such using mixers and tumblers or utilizing unscrupulous cryptocurrency exchanges are also being used to mask the flow of funds. Finally, the rapid increase in initial coin offerings (ICO’s) provides yet another outlet for cryptocurrency money laundering to occur.\nFortunately, advancements are being made on a variety of fronts to address the increase in illicit activity. First, the largest cryptocurrency exchange, Coinbase, has implemented a robust know-your-customer (KYC) program, as evidenced by my own experience of opening an account with the exchange. Secondly, researchers are finding new ways to extract information about certain cryptocurrency transactions which were previously thought to be unidentifiable. Finally, both law enforcement and government agencies, including the SEC and the Financial Crimes Enforcement Network, are using innovative, aggressive, and even clandestine techniques to combat cryptocurrency money laundering activity.
Purpose This purpose of this paper is to illustrate how terrorists finance their activities through cryptocurrencies. Design/methodology/approach A qualitative content analysis of 30 semi-standardized expert interviews with both illegal financial service providers and prevention experts developed understanding of the concrete techniques of financing terrorism through cryptocurrencies. Findings Terrorists could use Bitcoin to receive donations from their supporters. Research limitations/implications As the findings are based on semi-standardized interviews, they are limited to the perspectives of the 30 interviewees. Practical implications The identification of gaps in current prevention mechanisms is intended to provide legislators and intelligence agencies with insights into the operations of terrorism financers. Originality/value While the existing literature focuses simply on identifying areas that could play a role in financing terrorism, this paper describes concrete methods, taking both prevention and criminal perspectives into account.
Terrorism, Counterterrorism, and Political Violence
Achieving government’s goals for cannabis regulation requires legal cannabis to be a cheaper, more attractive consumer alternative compared to the illegal market. This goal may be undermined by the costs and disadvantages of traditional regulatory management. A Canada wide, real-time blockchain tracking system appears to be a viable technical solution architecture. A permissioned blockchain network could be tested alongside traditional tracking. This investment, if proven effective, could reduce regulatory costs for government and red tape for business, helping to achieve Governments’ objectives to:Enhance public safety by ensuring quality and monitoring product salesUndermine illegal markets to reduce crime and prevent product diversion
Obinna Ositadimma Oleribe, Olabisi Oladipo, Iheaka Paul Ezieme, Mary Margaret Elizabeth · 5 authors
Access to quality care is essential for improved health outcomes. Decentralization improves access to healthcare services at lower levels of care, but it does not dismantle structural, funding and programming restrictions to access, resulting in inequity and inequality in population health. Unlike decentralization, Commonization Model of care reduces health inequalities and inequity, dismantles structural, funding and other program related obstacles to population health. Excellence and Friends Management Care Center (EFMC) using Commonization Model (CM), fully integrated HIV services into core health services in 121 supported facilities. This initiative improved access to care, treatment, support services, reduced stigmatization/discrimination, and improved uptake of HTC. We call on governments to adequately finance CM for health systems restructuring towards better health outcomes.
Charles B. Holmes, Yogan Pillay, Albert Mwango, Jos Perriëns · 9 authors
Introduction To successfully implement the 2013 WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at country level, the implications for national and regional health systems need to be considered and addressed. The guidelines target the entire continuum of care for the HIV-infected individual, and in some cases, their partners, and those with unknown status. The guidelines include not only a more inclusive treatment initiation threshold of CD4+ T-cell count of 500 cells/μl or less for adults and adolescents, treatment for life for pregnant and breastfeeding women (or treatment for the duration of pregnancy and breastfeeding regardless of CD4+ T-cell count), treatment regardless of CD4+ T-cell count for children under 5 years of age, discordant couples, those co-infected with either tuberculosis (TB) or severe hepatitis B virus (HBV), and diversification of effective strategies to reach those with unknown status through couples testing and community-based testing. These changes, if fully enacted, will lead to an increase in treatment eligibility of over 60%, from 17.6 million globally, to 28.6 million globally, with variation in that increase by epidemic type and other epidemiologic factors [1]. However, within these increases in volume, health systems will be serving a healthier mix of patients starting antiretroviral therapy (ART), and greater proportions of pregnant women and children, and sexual partners seeking care together. The increased patient volumes and changes in the composition of those seeking care will require rapid attention to existing care delivery strategies in order to ensure that newly diagnosed individuals are served with the maximum efficiency and effectiveness, and others entering or already within the system under existing guidelines are not harmed. Additionally, to be successful over the long term, health systems and HIV programs will need strengthened adherence-support strategies. Systems of care that may already be stressed need to be further augmented through innovations, and in many cases provided with additional resources in order to become more efficient, resilient, robust and effective. The ‘Operations’ and ‘Service delivery’ sections (Chapter 9) of the guidelines address these challenges through recommendations for innovations in the models of service delivery, laboratory diagnostics and treatment delivery in the form of fixed-dose combinations (FDCs) to improve the efficiency, reach and quality of the prevention, care and treatment cascade. There are also potential gains from implementing the guidelines that could accrue to and strengthen health systems and communities, such as a healthier and more productive workforce and fewer new HIV infections, especially in newborns, and HIV-related hospitalizations, and these benefits must also be factored into HIV program and country-level decision-making surrounding adoption and adaptation of the new guidelines [2]. Our objective was to examine the implications of the new guidelines across the continuum of care for each of the elements of national health systems, starting with governance and the role of strategic planning and policy, and including diversification of service delivery models, generation and use of data, healthcare financing, human resource capacity, and supply chains for therapeutic and diagnostic commodities. Governance, strategic planning and policy The progress of discovery and change in the HIV epidemic have demanded a high degree of engagement with evolving evidence, as reflected in part by the 10 guidance documents on antiretroviral drug use issued by WHO since 2000. To date, national governments, with the support of civil society and cooperative partners, have employed a variety of approaches to new guideline adoption. Whereas earlier approaches often focused largely on clinical issues, there is now a need for much broader adoption processes to consider the complex interplay between clinical objectives, operational feasibility, issues related to equity, affordability and health systems capacity. In order to consider, adopt and implement new national guidelines with a broad coalition of support, Ministries of Health must take a strong leadership and governance role. When performed well, the key elements of the process at national level include the following: An inclusive and transparent consultative process that draws upon the best available resources, including program experts and managers, healthcare providers, civil society including people living with HIV, community and faith-based groups, key populations, technical specialists, other relevant government Ministries (e.g. Finance), budget experts and economists, researchers, academics, and health-related professional associations. Assembly, analysis and presentation of relevant clinical, programmatic and financial information. Consideration of guidelines changes in light of broader strategic policy frameworks cross-cutting a broader array of health, human rights and development issues. Clear decision-making mechanisms that allow consideration of competing demands. Clear articulation of roles and responsibility of various partners, in order to ensure accountability and oversight of the processes of change. Ensuring that the case for health in national development, including the potential benefits and risks of potential guidelines changes, is clearly communicated early and often to political leadership and external development partners. The recent process of developing and adopting new guidelines for antiretroviral drug use in pregnant and breastfeeding women in Zambia provides an instructive example of the range of activities needed to ensure that guidelines changes are made with broad stakeholder and health systems support (Fig. 1) [3,4]. National governments and civil society are encouraged to learn lessons from peers, and to participate in WHO's regional guidelines dissemination workshops that are designed to support strong national processes of guidelines change.Fig. 1: The process of changing prevention of mother-to-child transmission (PMTCT) guidelines in Zambia.Diversification and integration of service delivery models to manage patient volumes and improve retention and quality The expansion of HIV testing, care and eligibility for ART will require national governments and partners to consider how best to augment or modify their current health systems to accommodate increased volumes and new categories of patients, and to ensure retention across the care and treatment cascade. There is currently an over-reliance on a limited number service delivery models in many countries. Maximum expansion capacity and quality can be achieved by ensuring that a carefully selected variety of models are put in place and adapted strategically to take account of geography, epidemiology and local needs. Thus, it is an opportune time for governments and funders to focus on previously piloted models that are appropriate for scale-up, and to ensure that the most effective models are scaled up systematically in order to provide substantial complementary capacity to absorb new patients and provide ongoing care. Within the new guidelines, there is an increased emphasis on the importance of expanded national HIV testing and counseling strategies in order to identify ‘as many people living with HIV as early as possible after acquiring HIV infection, and link them appropriately and in a timely manner to prevention, care and treatment services’. The reality of most HIV-testing programs in most generalized epidemics is that they have been largely dominated by provider-initiated testing (most typically healthcare provider-initiated), which has been favored because of the ease of linkage to services and for its high yield and cost-effectiveness. However, it often identifies people living with HIV late in the course of HIV disease, in particular, men and adolescents, as well as key populations, who have low utilization of healthcare services. With the guidelines’ strong recommendation for community-based HIV testing and counseling with linkage to prevention, care and treatment services, governments should consider systematically expanding a number of approaches tailored for their settings, including mobile, door-to-door, index, campaign, workplace and school-based HIV testing and counseling approaches, and other strategies that ensure the inclusion of underserved groups such as children, adolescents and men. It is also important to recognize that the yield of nonclinic-based testing can be lower and more expensive from a human resource perspective, requiring a careful balance to be struck. For concentrated and low-level epidemics, governments are urged to consider guidelines that reflect WHO's strong recommendation to increase the number and diversity of the facilities in which provider-initiated testing and counseling are available, including sexually transmitted infection clinics, hepatitis and TB sites, antenatal care settings and services for key populations, notably MSM, transgender people, sex workers and people who inject drugs (Fig. 2) [5].Fig. 2: Innovative service delivery models to increase diagnosis and early antiretroviral therapy (ART) initiation among key populations in Indonesia.The capacity of national health systems to absorb the greater numbers of healthier, pregnant and individuals accompanied by partners eligible for treatment will be directly related to the extent to which ART sites are diversified, decentralized (and in some cases integrated into primary care services) and generally expanded. Extending care through different models will also relieve traditional ART sites and higher-level facilities and allow a greater focus on the sickest patients, especially in high-burden generalized epidemics. Models for consideration and rapid scale-up include ART initiation and maintenance for mothers and children in high HIV-prevalence settings integrated into antenatal care, and maternal and child health clinics, and for HIV/TB co-infected individuals into TB clinics, and other approaches that reduce the need of patients to come to clinics through community-based treatment clubs with rotating antiretroviral drug pick-up and home delivery, especially in remote rural areas. A systematic review on the impact of decentralization of ART delivery identified evidence from both randomized controlled trials and observational studies, and found that patients initiated at a hospital and maintained at a health center were more likely to be retained [6]. No difference in attrition was observed between those initiated and maintained on ART at a hospital compared to at a health center. Comparable attrition was observed after 12 months in the two trials in which ART maintenance was in the community [6]. Regions with measurable injection drug use may also consider the new strong recommendation for ART initiation integrated into clinics and sites in which opioid substitution therapy (OST) is provided. In areas with strong general outpatient services, integration of HIV services may yield greater equity with other health services, and may more directly enable HIV's chronic care models to benefit care and management responses to other chronic diseases such as diabetes and hypertension. These integrated sites must also be capacitated with on-site laboratories and referrals with a rapid turnaround for results reporting, especially for viral load, CD4+ T-cell count testing, TB testing and safety laboratories. Tiered laboratory systems must work closely with program leadership to ensure strategic investments in the best technologies for sites providing ART. Intentional analyses should be conducted to balance the convenience of point-of-care (e.g. CD4+ T-cell testing) technologies with the use of centralized high-throughput instruments. With anticipated rapid expansion of demand for viral load testing, it is essential to use internationally acceptable methods to locally validate the use of dry blood spots, as a means of viral load testing, which will allow expansion of this capacity without phlebotomy and cold chain capacity – the imminent availability of point-of-care viral load testing will also strengthen the health system's ability to provide good quality care. It is also critical to close the loop with results reporting via short message service or other secure electronic communication. Existing and new models also need to be chosen in order to intentionally retain patients in care and treatment, and ensure adherence to ART. Structural interventions such as increasing access points and decentralization through community-based models can address some of the most commonly cited reasons for disengagement with care (e.g. transport expenses, overcrowding of vertical sites). At an individual level, substantial evidence has demonstrated the benefits of two-way mobile phone text message systems, and WHO has made a strong recommendation for consideration of this approach [7]. As with numerous other proven methodologies, very few countries have systematically evaluated the needs of various vulnerable groups such as pregnant women, adolescents, key populations and healthy individuals starting ART and systematically taken appropriate packages of cost-effective adherence and retention interventions from the pilot phase, to scale. Generation and use of data for monitoring, evaluation, efficiency and quality improvement National and regional health systems of program monitoring and evaluation are fundamental to public health approaches to HIV prevention, care and treatment, and other chronic illnesses. When they work well, systems of measurement serve to provide actionable data for decision-making, starting with the clinician and service delivery sites, to regional and national program managers, related sectors (e.g. Ministries of Finance), and development partners [8]. Although the HIV response has focused substantial investments on monitoring and evaluation, the nature of the emergency response combined with weak health systems and the sheer volume of chronically ill patients have resulted in greater than expected challenges for many national systems. These challenges have been highlighted in recent studies demonstrating serious gaps in the ability of these systems to report on indicators that meaningfully measure program quality, and a lack of consistent data use at the site and regional levels to improve program quality [9]. With the influx of individuals seeking testing and care, and through sites and models not traditionally reporting on ART use (e.g. community-based antiretroviral drug pick-up and antenatal care sites), there are actions that must be taken coincident with guidelines adoption to ensure effective monitoring and evaluation of program quality. National governments and supportive cooperative partners must redouble efforts to harmonize and strengthen platforms for the use of data at levels of the health system to ensure that guidelines changes are as expected and that quality of care and patient are not models include or by the of health and development partners their implementing to review care and treatment at the and local These processes should be to and quality improvement processes that ensure clinical sites review their on critical elements of the care and treatment and have to to to quality and access to technical as on data use also to attention on the volume and of indicators and the systems that data A of potential indicators over the years has in some cases attention from those indicators considered at regional and national and countries are encouraged to their most critical indicators with the and ensure in the WHO's early indicators for HIV drug system of key indicators designed to quality improvement of ART services at level, with for and of the results for program management National governments and development partners also need to ensure systems are to allow reporting and use of the There are numerous and systems in few are fully integrated across the of care and treatment and at a national WHO is with numerous countries to improve integration of systems the Systems for HIV a of and guidelines to countries and implement a system that patient and and the impact in an integrated across maternal and child health of mother-to-child transmission and In WHO will consolidated strategic guidance that will a of indicators across the continuum of prevention, treatment and these will the key of quality HIV With this HIV program will have access to the critical indicators within with other When data are not to and important areas of the other methods may be including use of to more on critical issues that can with program quality, and traditional indicators and studies to the of critical program changes (e.g. studies of pregnant women starting ART CD4+ T-cell count of models and efficiency The HIV response ongoing and attention to to ensure the availability of for effective and with the Although the new guidelines will have much greater impact on health and of new and have the potential to reduce the of their are [1]. Ministries of Health and have critical challenges with new guideline to the and financial of potential guidelines changes in order to with local planning and to secure to support ongoing and changes to and to ensure the use of available of the of potential guidelines changes can be a variety of models, and some countries have been these of for As in of the guidelines, the of models is of the most commonly and its and resource needs models can be to the impact of guidelines changes on number of number of infections, and the of changing guidelines or approaches in a variety of epidemic models include the Health and models by the Health and for each with various and potential are encouraged to consider that is only as good as its ease of level of support, and attention must be in to ensuring the of local programmatic and Although has the of for the HIV response over the 10 years of the response in many low and some national governments have to increase their The ability of the in low and countries to further support the HIV and broader health response will be especially if traditional to These new guidelines a case for changing the course of the HIV and further resource may be by the of (e.g. more in antiretroviral drugs in the may reduce HIV that are less at for These may also be in the of such as the for Health and as for development of national that have the potential to provide a more for the HIV response and general health The has a to with to increase for methods for the efficiency by which the healthcare system resources to key and will also to and further resource For to the range of to provide ART to an individual, or provide an HIV testing and counseling by or of and for activities partners have made investments in developing these methods over recent and national governments are encouraged to to and resource use as the new guidelines are Ensuring human resource capacity to support evolving service delivery models of to the range of services to quality healthcare are a chronic in many countries. in many low and with of patients, are in some cases by only clinical and to long and for patients and a lack of attention to quality the new guidelines have many of the HIV interventions (e.g. a available in for HIV-infected and a focus on ensuring patients ART they HIV-related illnesses. These will further allow national programs to care delivery to who require less and to service delivery models and community delivery of The new guidelines also include recommendations for ART initiation to and for and community health workers to ART between has been a in the evidence for these recommendations and has successfully as a means of increasing the number of sites and to serve HIV-infected individuals (Fig. The effective use of in as a means of and expanding access to HIV care and as countries and scale-up new models of delivery, the guidelines changes provide a good to the current of various levels of and to use rapid evaluation to For the has that allow national governments to the need for additional healthcare workers on various guidelines These can also countries to approaches to and healthcare including laboratory These can form the for with professional of laboratory and and programs for other including community health workers and In order to the potential of the health including substantial numbers of new of health governments must to monitoring of program and ongoing support for the development of healthcare It is also important to frameworks to enable support and for new of health workers that have proven essential to the HIV including and community health These with the to have often been considered now are upon for delivery of services and must or and for Ensuring national supply chains are for the increase in volumes and changes in the mix of of the critical interventions in the new guidelines are on a consistent supply of essential commodities. Although national supply chains have in the 10 years of the HIV especially for antiretroviral drug there serious challenges in ensuring that clinics have For of rapid at the site level the efficiency and of and testing and prevention programs With more and expanded testing capacity for individuals their CD4+ T-cell count 500 cells/μl the case of and rapid expansion of viral load capacity, countries will to ensure that and related are with the of as antiretroviral activities for the of new guidelines include of the capacity of the and human resource capacity for transport and data management of the national supply for and need to include on antiretroviral drug that the use of fixed-dose in order to ensure adherence and supply the potential for viral load testing to up demand for and for additional HIV rapid (and other of care diagnostic such as point-of-care CD4+ T-cell and TB testing and and antiretroviral drug of of the of supply and of available technical and national of of with accountability at the levels of government and will likely have the with ensuring of key such as HIV rapid antiretroviral drugs and critical laboratory if their demand are communicated to their or supply and into The is important because the them and the to TB and work with to the demand for various of which the to the demand for their In the this and financial to of by of health services as well as civil society should be encouraged by national governments to ensure that are as early as possible that may be In the new WHO consolidated guidelines reflect not only evolving clinical also in the and of service delivery and program The most effective processes of guidelines change are by and reflect consultative processes in which and can be by partners with a in the It is expected that most countries will that there is a need to investments in the diversification of service delivery models, use and of data, development of human resources, and supply chains in order to accommodate increased patient volumes and to quality across the care and treatment cascade. and with careful for the essential elements of national health systems, the new guidelines could yield substantial for individuals living with HIV and public of There are of
In 2010, the fourth decade of the HIV pandemic arrived during a time of unprecedented success in HIV prevention. Globally, UNAIDS estimated that new HIV infections fell by 33% between 2001 and 2011; new infections among adults and adolescents fell by 50% or more in 26 countries (more than half of these countries were in sub-Saharan Africa), and new infections among children worldwide dropped by 52% [1,2]. The declines in new HIV infections are particularly evident in countries with sustained and more strategic investments, which take into account the specifics of local epidemics, increased political leadership and community engagement in response to the HIV epidemic, and scale up of HIV prevention and treatment programmes [2]. The rapidly growing delivery of antiretrovirals to women and infant feeding–based prevention programmes has resulted in a sharp decline in new HIV diagnoses among children. The encouraging declines in HIV infections can also be attributed to the improved effectiveness of combination antiretroviral treatment (cART), an expanded range of improved medications, the declining prices that make cART more accessible to people in low-income countries, growing coverage with HIV testing, and improved access to prevention and treatment services (particularly for women and young people in low-income countries). Global investment in the AIDS response jumped from US$3.8 billion in 2002 to US$18.9 billion in 2012. The new decade also saw a revolution in HIV prevention with ground-breaking scientific advances in HIV biomedical prevention, and specifically, proof that microbicides containing an antiretroviral agent can reduce sexual transmission of HIV to women by 39% [3], that earlier start of treatment by HIV-positive people (treatment as prevention or TasP) can reduce the risk of onward transmission by as much as 96% [4], and that consistent, correct use of a daily antiretroviral tablet by men who have sex with men (MSM) can achieve substantial reductions in HIV infections (pre-exposure prophylaxis or PrEP) [5]. In response to the excitement and optimism surrounding the preventative effects of antiretroviral medications, the UN member states considered and unanimously approved the new Political Declaration on HIV/AIDS at a special session of the General Assembly in New York in 2011 [6]. At the core of the 2011 UN Political Declaration are ambitious new HIV prevention targets calling on governments to commit to reducing sexual transmission of HIV by 50%, reducing HIV transmission though injecting drug use by 50% and eliminating mother-to-child transmission of HIV by 2015. These targets are aimed at reinvigorating the commitment towards achieving the Millennium Development Goal #6 to combat HIV/AIDS [7]. In the past two years, research on HIV biomedical prevention has focused on adapting the new prevention strategies to the context of local HIV epidemics [8]. There have been equal measures of optimism and pessimism expressed about the ability of new prevention strategies to halt the HIV pandemic. Based on the evidence that starting treatment earlier can increase health benefits and extend life for people with HIV [9,10], many clinicians are already recommending early treatment for both medical and TasP purposes. Regarding PrEP, the widespread reaction is caution in recommending this strategy. Such reluctance is based on concerns about the common adherence issues in the studies of PrEP [11], the obvious relationship between level of adherence to daily medication schedule and its preventative effect [12] and side effects and drug-resistant HIV [13], among others. Despite little evidence that PrEP use can affect behaviour, many concerns have been voiced about the future of safe sex practices, particularly condom use among MSM, if new biomedical prevention strategies are introduced. More research is needed to investigate this issue using appropriate study designs. In its current form, daily PrEP may benefit only a small number of people with very high and ongoing risk for HIV infection, and other PrEP regimens must be explored. The overarching concern about new prevention strategies, particularly PrEP, is that the cost and burden of providing them are currently unacceptable for most, even high-income, countries. As a result, there have been calls for more evidence and a very slow progress in implementing these two new exciting HIV prevention developments. Regarding PrEP, only two countries to date have prescription guidelines for people at high risk of HIV infection [14,15]. We now have the knowledge and new tools to revolutionize HIV prevention, and we have the bold new Political Declaration with ambitious targets. It must be acknowledged that the task of bringing HIV infections down to zero seems daunting from where we stand now in late 2013. Despite the global success in lowering the HIV infection rates by 33% [1], sub-Saharan Africa has seen only a 25% decline [16]. Some regions have seen increases (8% in Eastern Europe and central Asia [17], 19% in East Asia [18] and 37% in the Middle East and North Africa [19]). This lack of progress has been associated with insufficient resources, inadequate coverage of women with antiretroviral treatment and HIV testing programmes not reaching the population groups at high risk for HIV infection. While sexual behaviour has changed to become safer in some countries and populations, sexual risk taking has increased in other settings. This is the case in most high-income countries in North America, western and central Europe and Australasia, where MSM are central to local HIV epidemics. In these countries, both high-risk sexual practices among MSM and HIV infections have been on the rise [20,21]. Condom use has increased in some countries, but declined in others. Proven effective interventions (e.g., prevention of mother-to-child transmission (PMTCT) and needle- and syringe-exchange programmes) have not achieved sufficiently high coverage in many countries [1]. Although trends in risky sexual practices have been linked to the trends in HIV incidence [22] and population-level behaviour change to the reduction in HIV prevalence, there are still challenges in linking behaviour-change programmes to specific HIV outcomes on the population level [2]. While new expectations have been raised about the role of antiretrovirals for HIV prevention, mixed progress was observed in access to cART, and only 61% of people eligible for treatment under the 2010 WHO guidelines received it (this is as little as 34% under the 2013 WHO guidelines). The Political Declaration has for the first time named and acknowledged the importance of such population groups as MSM, people who inject drugs and sex workers for HIV prevention, but in many settings, stigma and access to treatment and prevention services for these groups are still important challenges. Many low- and middle-income countries have stepped up their local investments in HIV prevention [2], but, regrettably, the lack of resources has remained a major issue: only US$18.9 billion was available from all sources for the AIDS response in 2012, and this was estimated to be 16–26% short of annual need [1]. It is at this time of some successes in HIV prevention and challenges in how to optimize the available resources and tools that the aspirational Political Declaration of commitment to fight the pandemic is necessary. This year's International AIDS Day marks the midpoint towards the deadline set by the Political Declaration in 2011. It is an opportunity for governments and each of us to revisit and reinvigorate the universal commitment to bring HIV infections to zero. Like never before, we have good cause to expect the next generation to be AIDS-free and new HIV infections to move towards zero. In the face of the 75 million people who have suffered from HIV/AIDS and the many more affected, the international community should keep the promise and bring this HIV pandemic to an end. None were declared. The Kirby Institute receives project funding from the Australian Government Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. IZ has prepared the manuscript and approved its final version.
In the last decade, gay men and other men who have sex with men (MSM) have come to the fore of policy debates about AIDS prevention. In stark contrast to global AIDS policy during the first two decades of the epidemic which excluded MSM from policy outside the West, UNAIDS now identifies MSM as "marginalized but not marginal" to the global AIDS epidemic. This dissertation provides an account of this controversial reversal of global AIDS policy and uses it as a point of departure for understanding the role of intergovernmental organizations (IGOs) like UNAIDS in the formation of global health priorities.In contrast to the emergence of other health and social policy issues, various studies observe that efforts to establish a global agenda for addressing HIV and AIDS have been highly concentrated within intergovernmental organizations. How and in whose interests do new priorities emerge within AIDS IGOs? Health policy researchers argue that IGOs have considerable influence in the formation and dissemination of health policies around the world. However, there is a particularly rich debate among sociologists and political scientists about whether and how IGOs can act autonomously and pursue policy priorities that are not supported by states. Because these organizations generally lack enforcement power and are dependent on states for financial resources and legitimacy, IGOs have traditionally been conceived as lacking autonomy to pursue their own policy interests independent of the interests of states. Yet, recent interventions by sociologists have shown how IGOs strategically navigate the demands of states and even attempt to reconfigure the external environment to promote alignment with the policy interests of the IGO. Nonetheless, concerns about resources continue to plague IGOs and often constrain their agency. In this dissertation I argue that a key limitation of existing studies on the autonomy and influence of IGOs is their narrow focus on the decision-making and agenda-setting stages of policy making. I extend sociological research on the influence and autonomy of IGOs by addressing how concerns about implementation shape the particular structures and strategies that AIDS IGOs adopt in order to pursue their own policy interests. Many of these strategies are not easily understood by existing theories of IGO behavior which argue that as bureaucracies, IGOs will seek to expand their autonomy and influence in a sector. In contrast, I argue that IGOs with limited power to enforce policy implementation by states are highly sensitive to an implementation-autonomy trade off and may actually give up some autonomy in decision-making in order to facilitate broader implementation by states. IGOs also face additional barriers to implementation due to decentralization of the organization at the regional- and country-level and competition from other IGOs, nongovernmental organizations, and bilateral and private donors. Using archival data from World Health Organization's Global Programme on AIDS and its successor, the Joint United Nations Programme on HIV/AIDS (UNAIDS), two IGOs mandated by the United Nations to coordinate a global response to AIDS epidemic, I show in Chapter 1 how concerns about implementation have shaped decisions about the organizational structure of these IGOs. In addition, I show how implementation concerns have promoted the adoption of particular strategies - organizational inreach, interorganizational cooperation, evidence-based advocacy, and bidirectional pressure - to align policy preferences among states, other organizations, and even their own staff. The use of these strategies by AIDS IGOs has had consequences beyond the decision-making phase of policy development. Drawing on a novel dataset compiled from five waves of UN Country Progress Reports on HIV/AIDS (2003, 2006, 2008, 2010, and 2012), I show in Chapter 2 that the use of these strategies has promoted the alignment of national AIDS programs with UNAIDS policies on MSM over time. On the ground, IGO interest in HIV among MSM has also provided new technologies for seeing MSM in hostile political contexts. As I show in a country-case study presented in Chapter 3, claims for the recognition of same-sex sexualities in Malawi have had the most institutional success within the national AIDS programs which increasingly identifies MSM as a key target for public health intervention. Additionally, links between Malawian organizations and transnational research and advocacy networks have provided a context in which (male) same-sex sexualities have become statistically visible and institutionalized, providing a basis for future grassroots mobilization. At the same time, however, IGO interest in MSM has reinvigorated opposition to homosexuality among Malawian political elites and ordinary citizens. In Chapter 4 I introduce original household survey data collected in Malawi in 2012 (N=1491). Building on qualitative findings from Chapter 3, I use these data to quantitatively examine the effects of variation in aid allocations across Malawi's administrative districts on attitudes toward homosexuality. Results show that in districts with higher levels of annual aid per capita, individuals hold more negative views of homosexuality. Thus while IGOs have had a substantial effect on state-level and donor-level adoption of policy priorities, they have had much less success in changing public views toward homosexuality on the ground. These results suggest that models of global diffusion that utilize policy change as an indicator for cultural change may be greatly overestimating cultural change on contentious issues like homosexuality.In sum, IGOs have become central actors in the formation, diffusion, and implementation of AIDS policy concerning same-sex sexualities. They develop new policy ideas and set priorities that may diverge substantially from the interests of member states, both rich and poor. However, IGOs also face considerable barriers to implementing their policy priorities: from reluctant states to the decentralization of staff across dozens of country offices to competition from other organizations and private donors. In this dissertation I show how barriers to implementation shape the structures and strategies of IGOs. As such, this work contends that IGOs are not simply disinterested forums in which states pursue their own interests or passive collections of rules and norms, but autonomous, influential, and self-interested actors that shape the policymaking process and the world around them, sometimes in unexpected and undesirable ways.
Whether 15 million on antiretroviral therapy (ART) by 2015 is a realistic target or just a dream is posing the question in the wrong way. The real question is: how can we turn our dream of having 15 million HIV-infected people receiving adequate antiretroviral therapy in 2015 into reality? This issue of Current Opinion in HIV and AIDS, although far from comprehensive, provides building blocks to attain that goal, points out particular opportunities, but also identifies some of the obstacles that need to be overcome. The first article by Duncombe et al. (pp. 4–11) sets the stage by summarizing the WHO/UNAIDS Treatment 2.0 strategy. No need to duplicate or add to that here, because the article provides a thorough update on where we stand. One element needs to be highlighted, however: contributions of international donors have been stagnating over the past years, and although there is a continued increase in domestic funding, most African countries are far from reaching the Abuja Declaration targets for spending on healthcare. Sure, efficiencies in healthcare delivery can be improved [1], and the striking levels of fungibility or crowding out [2] may be tackled by innovative ways of donor financing [3]. But if there is too little money overall to provide decent healthcare, targets cannot be met. The second article by Vittoria and Vella (pp. 12–18) provides a very nice overview of the evolution of WHO HIV treatment guidelines, adapting to changing insights and possibilities throughout the years in an ever more timely manner. It also points at future trends, which take into account the beneficial effects early treatment can have on the health of individuals, HIV transmission, the incidence of tuberculosis and models of care delivery. If we do not succeed in simplifying models of care delivery, by decentralization and task-shifting a.o., we will be unable to reach the 15 million by 2015 target. The third article, by Hamers et al. (pp. 19–26) and the fourth article, by Sohn et al. (pp. 27–33) focus on transmitted HIV drug resistance in Africa and Asia, respectively, and point to an emerging and in some countries, like Uganda, already sizable problem. The Hamers article also presents data on the high rate of drug resistance mutations in those failing first-line therapy. It is clear that surveillance of both transmitted and secondary HIV drug resistance and measures to minimize the risk of their emergence (such as preventing drug stock-outs and increasing adherence) should be an integral component of the continuing ART scale-up. The 15 million target stands for 15 million people on effective, not failing, highly active antiretroviral therapy. Hill (pp. 34–40), in the fifth article, identifies three main problems with the current ART standard of care for many people in resource-poor settings: a large proportion of those on treatment are still taking stavudine-containing ART; there is limited diagnostic support – access to plasma viral load and drug resistance testing is still rare, which leads to late diagnosis of therapy failure and accumulation of drug resistance mutations; access to second-line treatment is limited. Thus, current practice often does not meet the standards deemed necessary by Hill to achieve ‘Universal Access’: a simple system of treatment, using a sequence of low-cost, coformulated antiretrovirals with strong efficacy profiles, nonoverlapping resistance profiles, and safety issues which are manageable with minimal medical expertise. He argues that only a relatively small subset of antiretrovirals may be needed for first-line, second-line and potentially third-line treatment in large-scale treatment access programs, and has several creative ideas about how this could be achieved in the most cost-effective manner, with a focus on ongoing research to use lower dosages of drugs (’dose-optimization’) which are cheap to manufacture. One can argue whether stavudine should have been included in this list, but, overall, simplifying therapeutic algorithms and lowering the dose and thus the cost of individual drugs are essential ingredients of a more effective scale-up. The sixth article (pp. 41–49), by the ‘fathers’ of Treatment as Prevention (TasP), advocates passionately for expansion of combination HIV prevention with an emphasis on the merits of expanding treatment: there is increasing evidence of health benefits of earlier treatment, a sharp reduction in incidence of tuberculosis in HIV-infected individuals, and with viral suppression through effective ART the risk of passing on the virus from a person living with HIV to a negative partners is close to zero. The authors remind us about the early skepticism regarding the feasibility and advisability of delivering ART in resource-poor settings, and how these skeptics have been proven wrong. Yes, we should never ever be discouraged by ‘the nattering nabobs of negativism’ (to use a phrase from the recently deceased William Safire). But we can also not be naïve and ignore the potential risks. The path to ‘Test and Treat’ will be paved by identifying – and managing – the potential risks; long-term side effects, and development of significant drug resistance, for example, because of breeches in adherence in particular of people living with HIV who have never been sick and as such have not felt themselves the dramatic benefits of treatment and full reconstitution of ill-health. The question should be less whether or not to treat earlier. But much rather about the ‘how’ and what needs to be in place to minimize, track and manage the potential risks. Let us move intelligently, and while proceeding, watch carefully for possible negative effects to take corrective action, and take the emerging results and lessons of ongoing TasP demonstration projects into account. The seventh article, by Hankins and Dybul (pp. 50–58), is a thorough review of the evidence for pre-exposure prophylaxis (PrEP), with either local (e.g. vaginal microbicides) or systemic (e.g. oral) use of antiretrovirals. Based on the positive results of several clinical trials, oral PrEP with Truvada [tenofovir disoproxil fumarate/emtricitabine (TTDF/FTC)] has now been approved by the United States Food and Drug Administration (FDA) to reduce risk of sexually acquired HIV infection in high-risk adults. Public health experts are struggling with how to translate scientific findings from PrEP effectiveness trials into real-world implementation. For several reasons PrEP cannot be seen in isolation from treatment, and thus deserves a place in this issue of Current Opinion in HIV and AIDS. First: the same drugs (TDF and FTC) that are used for PrEP are a mainstay of ART regimens (for this purpose lamivudine is considered similar to FTC), which is not an ideal situation considering the risk of HIV drug-resistance development. Second, both human and financial resources for the treatment scale-up are already limited; are we now going to spend resources on these relatively expensive drugs for prevention, while, in addition to the effect of HIV treatment on HIV transmission, other HIV prevention modalities are available (male and female condoms, male circumcision)? Hankins and Dybul carefully review the prerequisites for, challenges to and dilemma's of a PrEP rollout. They also briefly review exciting products in the pipeline, including long-acting agents. The cascade of HIV care, which has the ultimate aim to achieve and undetectable plasma viral load – for the benefit of the individual and to prevent onward transmission – goes way beyond ‘Test and Treat’. It also involves linking people to care after a positive HIV test, retaining them in care, getting them to initiate ART (if they want so), and getting them to adhere to the treatment regimen. All assuming that the care given is adequate, and that the antiretrovirals are present every time and of good quality. In the eighth article of this issue, with the catchy title ‘Patching a Leaky Pipe’, Kilmarx and Mutasa-Apollo (pp. 59–64) review the recent literature on these multiple Achilles’ heels of the treatment scale-up. Fixing just one or two is not enough: they can all work as ‘chain terminators’. Carefully examining the gaps at each step of the cascade, country by country and community by community, will be among the most useful approaches for planers and decision makers to improve scale-up and quality of care – essential elements to reaching and keeping the 15 million on ART. Article number nine, by Samuel Oti (pp. 65–69), who has the privilege to work at the unique African Population and Health Research Centre in Nairobi, is a compassionate and well reasoned plea for a coordinated response to HIV and noncommunicable diseases (NCDs). It is amazing that the advantages of this are not yet evident to everyone. How can we defend testing every adult for HIV and not take a blood pressure measurement at the same time. Hypertension is the biggest risk factor for premature death in the world [4] and its treatment is relatively straightforward and affordable. To secure continued funding for HIV it is essential to show that this money adds value beyond HIV and helps to build viable and sustainable health systems. Last but not least, article number 10 in this issue, by ‘t Hoen and Passarelli (pp. 70–74), looks at the role of intellectual property rights in HIV treatment access. It is hard to understand for us, why thus far only one research-based pharmaceutical company (Gilead) has had the courage and common sense to contribute to the Medicines Patent Pool. What are the others afraid of and what do they want to accomplish? However, we are living in a rapidly changing world and access to medicines is a complex issue beyond licensing agreements. With significant economic growth in the developing world the old concepts of rich and poor countries are increasingly invalid. Already today, the significant majority of all people living with HIV is living in middle and high-income countries, up from less than one-third, 10 years ago. And this trend is to continue. We need new approaches to access and equity, differential pricing approaches that address poverty within a given country, more systematic approaches to price negotiations that protect the smaller and less powerful states in their attempts to negotiate access to life-saving medicines, and the full use of TRIPS flexibilities including compulsory licensing if we are to reach the 15 million, and beyond. All in all, although some pieces, like healthcare financing, are missing, this issue of Current Opinion in HIV and AIDS presents a relevant mix of articles about opportunities of and challenges to a continued antiretroviral therapy scale-up. It has been a privilege to have served as its editors. J.M.A.L. and B.S. Acknowledgements None. Conflicts of interest J.M.A.L. institution has been receiving educational grants from the following pharmaceutical companies: Abbott, Boehringer Ingelheim, Bristol Meyers Squibb (BMS), Crucell, Gilead, ViiV, Johnson and Johnson, Merck, Mylan, and Roche. I have received honoraria for speaking engagements or consulting from Bristol Meyers Squibb, Gilead, Roche and Tibotec (Johnson and Johnson). B.S. has no conflicts of interest.
Serge‐Paul Eholié, François Eba Aoussi, Ismael Songda Ouattara, E. Bissagnené · 5 authors
Many successes have been achieved in HIV care in low- and middle-income countries (LMIC): increased number of HIV-infected individuals receiving antiretroviral treatment (ART), wide decentralization, reduction in morbidity and mortality and accessibility to cheapest drugs. However, these successes should not hide existing failures and difficulties. In this paper, we underline several key challenges. First, ensure long-term financing, increase available resources, in order to meet the increasing needs, and redistribute the overall budget in a concerted way amongst donors. Second, increase ART coverage and treat the many eligible patients who have not yet started ART. Competition amongst countries is expected to become a strong driving force in encouraging the least efficient to join better performing countries. Third, decrease early mortality on ART, by improving access to prevention, case-finding and treatment of tuberculosis and invasive bacterial diseases and by getting people to start ART much earlier. Fourth, move on from WHO 2006 to WHO 2010 guidelines. Raising the cut-off point for starting ART to 350 CD4/mm(3) needs changing paradigm, adopting opt-out approach, facilitating pro-active testing, facilitating task shifting and increasing staff recruitments. Phasing out stavudine needs acting for a drastic reduction in the costs of other drugs. Scaling up routine viral load needs a mobilization for lower prices of reagents and equipments, as well as efforts in relation to point-of-care automation and to maintenance. The latter is a key step to boost the utilization of second-line regimens, which are currently dramatically under prescribed. Finally, other challenges are to reduce lost-to-follow-up rates; manage lifelong treatment and care for long-term morbidity, including drug toxicity, residual AIDS and HIV-non-AIDS morbidity and aging-related morbidity; and be able to face unforeseen events such as socio-political and military crisis. An old African proverb states that the growth of a deep-rooted tree cannot be stopped. Our tree is well rooted in existing field experience and is, therefore, expected to grow. In order for us to let it grow, long-term cost-effectiveness approach and life-saving evidence-based programming should replace short-term budgeting approach.
Internet and digital technologies have been discussed recently by Addiction contributors in relation to the delivery of efficient computer-delivered brief interventions [1,2], online methodologies for recruiting and surveying illicit drug users [3] and the internet's role in facilitating the spread of information and sale of emerging drugs such as mephedrone [4] and synthetic cannabinoids [5]. Here, I introduce readers to a novel use of the internet in the drugs field. The anonymous online drug market-place Silk Road was first revealed in June 2011 [6]. Silk Road is accessible only to people who are using Tor anonymizing software [7]. Tor uses encryption to make it impossible for anyone to trace IP addresses (the electronic code assigned to each computer on the internet). The front page of Silk Road looks a great deal like the front page of eBay. Goods and services for sale are categorized and all manner of drugs are available under the following categories: ecstasy, cannabis, dissociatives, psychedelics, opioids, stimulants, benzodiazepines and other. Sellers receive ratings from buyers and comments about the quality of their products, how fast they ship and the level of professionalism and discretion of the transaction. Trust in sellers is built on reputation. Silk Road traders use the anonymous currency Bitcoin [8]. This decentralized international currency operates through peer-to-peer technologies. At the time of writing (October 2011), Silk Road is still online and continuing to expand. Facilitated by a combination of the internet and encryption technologies, buying and selling illegal products is now possible and may increase dramatically in the future. What may stop an exponential increase in the use of anonymous online drug market-places is the hurdle of delivery. At the end of the transaction, the physical product still needs to be sent to the buyer. Sending products between countries allows law enforcement the opportunity to intercept packages and potentially attempt to arrest the would-be importer. Sending products within the same country may make arrest less likely. There are also numerous barriers to entry for people who might want to use Silk Road. Installing and using Tor, buying and using Bitcoins in a secure way and taking the risk of fraud or arrest upon delivery may deter the majority of would-be users. Nevertheless, for the minority who master these concerns and are willing to take the risk, Silk Road has revolutionized how the internet can be used to source drugs. After all, buying drugs in the real world also involves considerable risk. For some, the online equivalent may prove more convenient and secure than arranging a standard deal. There are many unanswered questions about Silk Road. The extent to which law enforcement can stop and disband a site such as this is yet to be seen. The extent to which drug users will use this new technology is also unknown. Needless to say, if anonymous online drug markets do end up expanding into mainstream drug markets, they will pose a real challenge to existing drug laws and policies. We should definitely watch this space. None.
Rifat Atun, Martin McKee, Francis Drobniewski, Richard Coker
OBJECTIVE: To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. METHODS: Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. FINDINGS: We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. CONCLUSION: Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.
:The development and spread of Acquired Immunodeficiency Syndrome (AIDS) in American urban areas is challenging established policy making structures and patterns in a variety of ways. AIDS is forcing urban policymakers to engage in unusual efforts at large and nonincremental change while possessing relatively little understanding of the ultimate nature and course of the disease. A variety of uncertainties exist, involving the future scope and development of AIDS, current and future treatment costs, legal and administrative responsibilities, workplace concerns, education efforts, financing methods, and political effects. As a consequence, those making AIDS policy must rely upon what Jones (1984) terms ambitious decisionmaking styles. Successful control of AIDS will require decentralized policymaking centered on experimental efforts in each urban area confronted with the disease. Given the wide range of uncertainties regarding the nature of AIDS and effective policy measures, it is unlikely that a truly national AIDS policy will be established in the immediate future.