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“Getting to Zero: Zero new HIV infections. Zero deaths from AIDS-related illness. Zero discrimination” is the theme of World AIDS Day 2012 on 1 December. Life-saving antiretrovirals have reduced new HIV infections and deaths. The 2015 target of 15 million HIV-infected people on antiretroviral medicines worldwide looks more achievable now than ever before.
World AIDS Day – BMJ special promotion
The BMJ Group is putting together a special promotional webpage for World AIDS Day on 1st December that will offer a week’s free access to all relevant content published by our full range of journals. Please click here for access
New resources for young people living with HIV
To mark World AIDS day on the 1st of December, the Children and Young People HIV Network, based at leading children’s charity the National Children’s Bureau, is sending a message of support to young people with HIV by launching a range of materials to support them in managing life with the condition.
The ‘Your Life’ leaflets and the ‘Studying with HIV’ guidance and LifeLinks resources are all available from www.ncb.org.uk/hiv
More than Half of those with HIV in the UK are Overweight: The Surprising Issues Facing Those Living with HIV
The British Dietetic Association (BDA) will once again be supporting World Aids Day on 1st December. Early data from the BDA’s DHIVA specialist group audit suggests that more than half of people living with HIV in the UK are overweight or obese, with only about one-in-nine being underweight.
In fact by far the most common issues facing HIV dietitians in the outpatient clinic these days are dyslipidaemia, hypertension, diabetes and osteoporosis, with over 75% of HIV patients Vitamin D deficient. Dealing with these issues is not as straightforward as it might seem, with HIV-specific barriers to lifestyle change emerging.
Members report common themes from their patients, including a fear that deliberate weight loss might lead to others guessing their HIV status (“why are you getting thin – you don’t have AIDS do you?”), and a feeling that being overweight is safer (“I remember how ill and thin I was before starting ARVs and I don’t want to go back there again”). from Alastair Duncan, Chairman of the BDA’s DHIVA (Dietitians in HIV/Aids) specialist group.
UNITAID welcomed the good news this World AIDS Day that the number of children newly infected with HIV continues to decline but urges the international community to step up efforts for those children already living with the disease. more from the website
WHO – 40 years of innovation in sexual and reproductive health
A comment piece in The Lancet by past and present directors of WHO’s Human Reproduction Programme (HRP) discusses the achievements of the Programme since it was established in 1972.
Online First – Evaluation of a community pharmacy delivered oral contraception service
“Anything for the weekend … and beyond, madam?” Community pharmacies increase oral contraceptive uptake
Parsons et al.’s evaluation of a community pharmacy delivered oral contraceptive (OC) service is of particular interest, as it demonstrates the value of providing OCs via this service outlet, especially for women who would not otherwise access long-term contraception. Between 2009 and 2011, seven specially trained pharmacists at five pharmacies in South-East London provided OCs under a Patient Group Direction (PGD) during 741 client consultations. The evaluation showed that trained pharmacists were clinically competent to provide OCs according to a PGD, and that the service was successful in attracting the population identified as most in need. Nearly half of all consultations occurred following emergency hormonal contraception supply, and nearly half of clients receiving an initial supply of OCs were first-time Pill users. Based on satisfaction questionnaires from a small sub-group, most clients valued this service, were happy about privacy, and would recommend it. Although the primary aim was to reduce teenage pregnancy , and nearly a quarter of clients were aged <20 years, the study shows that women aged 20+ years also require this service and should not be overlooked when formulating policies for service provision. summary by Walli Bounds, Associate editor
Infertility: Survey shows nearly half of all GPs lack knowledge
Results of a comprehensive patient survey by the National Infertility Awareness Campaign (NIAC) shows that GPs need to be better informed about infertility treatment, including IVF, and the options available when the commissioning of IVF switches to local commissioning groups next year. The NIAC survey found that nearly 50% of GPs lacked the necessary knowledge of infertility and the treatment options available to provide an effective service. This could explain why some patients with fertility issues perceived their GPs as unsympathetic.
Calling All Baby Boomers: Get Your Hepatitis C Test
A report issued by the U.S. Centers for Disease Control and Prevention (CDC) recommended that all Americans born between 1945 and 1965 be tested for the hepatitis C virus (HCV). An estimated 2.7 million to 3.9 million people in the United States are infected with this liver-damaging—and sometimes lethal—virus, and many do not know they carry it. CDC calculates that roughly 75% of those infected are baby boomers: 3.25% of people born in that “birth cohort” test positive for HCV, which is five times higher than the rate in adults born before 1945 or after 1965. CDC has determined that universal testing of baby boomers is the most cost-effective strategy for detecting undiagnosed HCV infections. As reported in Science
New lab for HIV research
The Indian Government has opened the new $12 million HIV Vaccine Translational Research Laboratory in New Delhi. The new Laboratory will aim to recruit around 30 scientists with the goal of creating a new vaccine against HIV, and will work in collaboration with the International AIDS Vaccine Initiative. As reported in Science
From the New England Journal of Medicine: A large (7486 paticipants) prospective cohort study, by researchers at Washington University School of Medicine in St. Louis, to evaluate contraceptive methods has found dramatic differences in their effectiveness. Women who used pills, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device (IUD) or implant.
And from the American Journal of Obstetrics & Gynecology
The purpose of this study in Colorado was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant insertion and showed excellent continuation 1 year after delivery; rapid repeat pregnancy was significantly decreased compared with control participants.
The objective of the study from South Carolina was to improve the understanding of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy. LARC use was associated with older age, high IUD knowledge, and earlier onset of sexual activity and concluded that increasing knowledge of IUD among certain groups may improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy.
The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.
The study aimed to determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics in North Carolina. They concluded that clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.
International Campaign for Women’s Right to Safe Abortion
The ICMA have launched a new international campaign for women’s right to safe abortion. Individuals and organisations are invited to join the campaign in advance of 28 May, the International Day of Action for Women’s Health. To read more and to register support go tohttps://www.surveymonkey.com/s/CHH62F5
UNFPA announces ‘Maternal Deaths Halved in 20 Years’.
The number of women dying of pregnancy and childbirth related complications has almost halved in 20 years, according to new estimates released by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Bank.
US regulators vote for approval of PrEP by large majority.
The US Food and Drug Administration (FDA) have taken a decisive step towards approving the use of the combination pill Truvada (tenofovir/FTC) as a prevention method for HIV-negative people. Read more atNAMaidsmap. GlobalData.com reported on 11th May – In a controversial decision on May 10, the FDA antiviral drugs advisory committee backed Gilead Sciences’ drug Truvada to prevent the transmission of HIV. The committee voted in favour of prophylactic Truvada in three populations: HIV-uninfected men who have sex with men (19-3), in HIV-uninfected partners in relationships with infected partners (19-2), and for individuals at risk of acquiring HIV through sexual activity (12-8). Although awareness of HIV and AIDs has significantly increased throughout recent decades, the disease remains a global epidemic requiring better preventative strategies. Yet the possibility that on June 15 the FDA will approve Truvada for pre-exposure prophylaxis (PrEP) has provoked strong and divided opinions from infectious disease experts and activists. Read more at globaldata.com
Victories for Center for Reproductive Rights
Victory for Honduran Women
On May 17, 2012, the Center for Reproductive Rights held a demonstration on the steps of the Honduran Congress. Their mission: to stop the government from passing a bill that would have imprisoned women for using emergency contraception. Alejandra Cárdenas, Legal Adviser for Latin America and the Caribbean, had planned to personally hand-deliver 730,000 petitions to the Congress signed by activists in more than 80 countries in protest. In a surprise move, Juan Orlando Hernández, president of the Congress, declined to take the petitions—but not because he didn’t hear the massive outcry. In fact, Hernández said he no longer planned to bring the bill up for debate—and even proclaimed support for women’s self-determination. Read more:
Two Groundbreaking Victories in Oklahoma:
Medication Abortion Protected
Judge Donald Worthington permanently blocked a state ban on medical abortion when he ruled that the law was “so completely at odds” with standard medical practice that it “can serve no purpose other than to prevent women from obtaining abortions and to punish and discriminate against those women who do. Read more:
and Oklahoma Personhood defeated
With a unanimous decision by the Oklahoma Supreme Court, the Center for Reproductive Rights has won its legal challenge to strike down a ballot initiative that would have given every fertilized egg the full legal rights of a person. It is not acceptable, they ruled, to propose amendments to the state constitution that are ‘repugnant to the Constitution of the United States.’” If passed, the amendment not only would have outlawed abortion in all cases—including in cases of rape or incest, fetal anomalies, or risk to a woman’s life—but also would have banned many forms of birth control and seriously threatened fertility treatments such as IVF. Read more:
Distress of child war and sex abuse victims halved by new trauma intervention
A new psychological intervention has been shown to more than halve the trauma experienced by child victims of war, rape and sexual abuse. Researchers at Queen’s University Belfast pioneered the intervention in conjunction with the international NGO, World Vision as part of a wider programme to treat psychological distress in child victims of war and sexual violence in the Democratic Republic of Congo (DRC). Read more:
Melinda Gates’ New Crusade: Investing Billions in Women’s Health
Melinda Gates this week pledged billions of dollars to be spent on improving access to contraception. In her many travels she repeatedly met women who were unable to gain access to something which most of the rest of the world take for granted. In an interview with Newsweek she recounted stories from the women many of whom were unable, for example, to get repeat injections of Depo Provera. In July she is teaming up with the British government to cosponsor a summit of world leaders in London, to start raising the $4 billion the Foundation says it will cost to get 120 million more women access to contraceptives by 2020. And in a move that could be hugely significant for American women, the Foundation is pouring money into the long-neglected field of contraceptive research, seeking entirely new methods of birth control. Ultimately Gates hopes to galvanize a global movement. “When I started to realize that that needed to get done in family planning, I finally said, OK, I’m the person that’s going to do that,” she says. More from the Gates Foundation website.
Paper confirms EC IUD failure rate less than 1 per 1000
Authors of the first ever systematic review of all available data from the last 35 years argue that IUDs should be routinely offered and available to those requesting emergency contraception. They found that the failure rate was less than 1 per 1000 when they analysed data from 42 studies involving 7034 women using 8 different IUDs. They also found that 85% clinicians in one study never offered this as an option. In a press release this week one of the authors, Professor James Trussell, said:
“This is an extremely difficult problem to deal with, especially as in many countries women can just go to their local pharmacy to obtain the ‘morning after pill’, but virtually no women know to ask for an IUD and many family planning clinics and surgeries do not offer same-day insertion. Offering same-day insertion would remove a huge barrier to the greater use of IUDs.”
Online First – Postnatal contraceptive choices in HIV-positive women [Duncan et al.]
Gillian Robinson (Associate Editor) writes:
“This paper describes an exciting example of how an integrated contraception and sexual health service can work to provide holistic care for women. This clinic provides women living with HIV with prenatal, antenatal and postnatal care in a community setting. The paper is a retrospective case note review. Uptake of postnatal contraception was high yet more than 20% of women were not seen postnatally. The authors suggest that the reasons for this are explored to ensure all women with HIV receive contraception in the early postnatal period to prevent unwanted pregnancy.”
NAT calls for new health bodies to tackle late diagnosis of HIV
“Halve It”, a broad coalition of leading experts and advocates in HIV and AIDS, welcomes the renewed call by the National AIDs Trust (NAT) for the urgent prioritisation of HIV testing in its new ‘HIV testing action plan’ which provides vital strategic guidance to health bodies on tackling the serious issue of late HIV diagnosis in the UK.
FDA Approves first pill for Heavy Menstrual Bleeding (HMB)
Natazia is a combination oral contraceptive (COC) consisting of estradiol valerate and estradiol valerate/dienogest. The US Food and Drug Administration (FDA) first approved Natazia in May 2010 to prevent pregnancy. On March 14, 2012, the FDA also approved Natazia to treat heavy menstrual bleeding (HMB), making it the first and only OC indicated for this purpose. One interesting thing is that until now we have known Natazia, in the UK, as Qlaira and until now it has not been widely used. More details at Medscape.
UK women misdiagnosing genital infections
To mark National BV Day on 18th April a study found that one in four British women has misdiagnosed themselves on the internet. Researchers found Dr Google is now the first port of call for women with genuine health concerns who are almost twice as likely to check online before consulting a doctor or even talking to Mum. But searching their symptoms online and self-medicating has led a tenth of the country’s women to endure unpleasant side effects as a result of their misdiagnosis.
Last year the Royal College of Obstetricians and Gynaecologists published ‘High Quality Women’s Health Care: a Proposal for Change’ that proposed a radical change to the structure of UK women’s health services. Andrew Horne and Johannes Bitzer discuss this exciting document from both a UK and a European perspective, commenting on its implications for sexual health provision. See page 68
Gonorrhoea infection is increasing in the UK with a 3% increase in cases between 2009 and 2010. Last year there was a report of a ceftriaxone-resistant isolate; there is a growing concern that gonorrhoea may become incurable. The commentary by Taylor and Bignell is timely. It reviews the current position and provides clear guidelines on screening and treatment, which may prove challenging for some community services that rely exclusively on the use of nucleic acid amplification tests. See page 70
At last, a COC licensed for use in a flexible extended regimen
Data are presented from Phase III studies of a 20 µg ethinylestradiol/3 mg drospirenone combined pill, designed to be used in a flexible regimen. The studies evaluated the efficacy of the regimen, bleeding patterns, safety (ie, metabolic and endometrial parameters) and effect on dysmenorrhoea. Comparisons were with a fixed extended regimen and the conventional 24-day regimen. Results show good efficacy, tolerability and safety with the flexible regimen, and a significant reduction in both bleeding and dysmenorrhoea. See pages 73, 84, 94
Does hormone replacement therapy cause breast cancer? Part 4. The Million Women Study
Shapiro et al. continue their review of breast cancer and hormone replacement therapy papers, this time focusing on the Million Women Study. They conclude that despite its massive size, this study did not satisfy causal criteria. The online version of this paper has already been the focus of a great deal of media publicity and both a news piece and an editorial in the BMJ. Readers should also look at the Letters section for related correspondence that the Journal has received as a result. See page 102
A new aid to diagnosis
Ultrasound imaging has been of value to our specialty for over two decades and skills and equipment have steadily become more available within sexual and reproductive health clinics. In their article on hysterosonography using a local anaesthetic gel, Pillai and Shefras present their experience with a simple and effective new technique that takes imaging a step further, allowing clear diagnosis of intrauterine abnormalities, particularly causes of abnormal bleeding or failed intrauterine device/system (IUD/IUS) insertion, as well as aiding location and easier retrieval of IUDs with missing threads. Many readers will be familiar with the use of lidocaine gel to aid IUD insertion: not surprisingly, uterine instrumentation in conjunction with scanning was reported to be less painful with this technique. This is a promising approach to simplifying and improving the cost-effectiveness of care for women presenting with some complex contraception problems. See page 110
Abortion legislation in a changed world
In his latest Legal Opinion article, Sam Rowlands reviews legislation governing early medical abortion (EMA) and the licensing of EMA drugs in the UK and in other jurisdictions. He then looks at the ways in which such legislation has been used – or in some cases circumvented. EMA has helped to fulfil the crucial need for safe abortion worldwide, but in the author’s view the laws governing abortion in most countries are out of step with scientific advances. Readers may find the author’s conclusions and suggestions for future changes to our own abortion laws thought-provoking. See page 117
Role of doulas in abortion care
Doulas, or lay support persons, have had a longstanding role in supporting women in labour. Chor et al. argue that their role should be extended to caring for women having abortions, where they can help women relax and provide information. They suggest that engagement of the medical community will be instrumental in successfully expanding the role of abortion doula programmes within abortion provision. See page 123
Abortion in the classical world
Lesley Smith continues her series on the history of contraception and reproductive health with a look at attitudes to and practices of abortion in ancient times. It appears that even then, abortion was at the heart of much medical ethical debate. See page 125
Status of health professionals in the 21st century
Has the status of health professionals in society today fallen? If so, why? And is it a good or a bad thing? The Journal’s Consumer Correspondent, Susan Quilliam, explores the issue in her latest article. See page 127
Twenty-five years on: HIV remains a concern
In his latest ‘Then and Now’ article, Lindsay Edouard looks at topics covered by this Journal in 1987. New approaches to contraception were emerging. But was there a threat to community family planning services and would litigation faced by USA manufacturers restrict contraceptive choice? However, the major concern was the emergence of HIV/AIDS, with reinforcement of the advice that barriers should be used in addition to hormonal methods. In 2012, in the light of controversial research suggesting a possible association between hormonal contraception and increased HIV risk in some settings, Edouard draws our attention to the WHO very recent guidance regarding dual protection: 25 years on, advice has not changed. See page 131
Plus – Online Poll
Will the recent article on hormone replacement therapy and breast cancer alter your prescribing practice with regard to HRT?
The latest edition of FSRH News is available on the website.
The January edition of the Journal of Family Planning and Reproductive Health Care includes a number of articles previously available at Online First (the Dinger/Shapiro VTE commentary, Advances in IUD training by Connolly & Rybowski and Brown’s study looking at young mens’ views on contraception) as well as:
a thought-provoking commentary by Raine-Fenning et al on pregnancy of unknown location (PUL) which points out that a recent recommendation from CMACE to abandon the term is at odds with current scientific evidence and clinical experience;
a commentary by Wilkins of the Men’s Health Forum on men and sexual health;
a study by Draper et al on 525 GP fittings over a period of 30 years confirms that routine IUD checks confer no benefit. The paper suggested that current guidelines recommend annual checks though this is based on a statement from Australia dated 2007 and USA advice from 2000 and ignores more up to date FSRH and WHO guidance;
a questionnaire study of clinic attendees and staff about what we should call ‘attendees’. This appears to show that there is a preference to retain the term ‘patient’ but was based on the respondents picking from only 4 options (‘patient’, ‘client’, ‘user’ or ‘customer’ – ie didn’t include ‘women’ and ‘men’) or asking them what they would prefer to be called;
Kipp et al highlight the unmet need for effective methods of FP in HIV+ individuals in rural Uganda;
womens’ views of the use of their leftover LBC samples for research purposes (Cooper et al);
an important restrospective audit comparing unscheduled reattendance among women having EMA (early medical abortion) at home vs hospital (Astle et al);
a review of appropriate use of Co-cyprindiol in a general practice (Tandy);
a review of Clomifene use for ovulation induction in general practice (Wilkes & Murdoch)
Sharon Cameron and her colleagues in Edinburgh created a fast-track referral service so that women who had undergone early medical abortion who wished to use intrauterine contraception afterwards could be seen promptly for IUD/IUS fitting. However, only about half the women who were given appointments actually attended. In their article they analyse the differences between the attenders and the non-attenders and suggest ways to enhance the uptake of these effective methods for the prevention of further unwanted pregnancies. While some women would benefit from IUD/IUS insertion at the place of abortion, provision of a fast-track service to the family planning clinic may yet remain the best strategy for maximising uptake of intrauterine contraception in this specific client group. from David Horwell, Advisory Editor, JFPRHC
Journal Fiction Book Reviews for April 2012: The fiction book that has been reviewed for the next Journal is:“Sense of an Ending” by Julian Barnes. Read this and see if your views coincide with our reviewer. If anyone has read “The Marriage Plot” by Jeffrey Eugenides and would like to review it and see their review in print in the April issue please submit a maximum of 400 words to email@example.com by 12 February at the latest. In addition, let us know if there are any other books you have read recently that you feel would be of interest to readers.
New mobile website for Brook Brook, the young people’s sexual health charity, have launched a version of their website optimised for viewing on a mobile phone, funded by the JLS Foundation. See a screenshot of the new site below:
It has been a busy and eventful year in sexual and reproductive health:
saw the launch of the new-look Journal of Family Planning & Reproductive Health Care as it joined the BMJ family. Readers will have noticed many improvements, not least the website and early online publishing.
Consultation to lift ban on HIV-positive doctors and dentists: according to media reports last week the DH is set to launch a consultation on lifting the ban imposed 20 years ago. Many believe the ban to be discriminatory, no longer justified on public health grounds and ignored in most hospitals who reportedly have a ‘don’t ask, don’t tell’ approach. The DH’s own expert group concluded that the risk of infection was in the region of one case in every 2400 years.
Correlation of Age at Oral Contraceptive Pill Start with Age at Breast Cancer Diagnosis Based on a review of 1010 cases at the Breast Unit in Ashford, Kent and published in The Breast Journal – early view this week, the authors concluded that the age when the OCP was started was positively associated with the age when breast cancer was first diagnosed. They state that this effect may show a causal link but may also reflect other associated lifestyle factors associated with early OCP use.
Faculty Members Questionnaire
The FSRH are conducting a short questionnaire to elicit members’ views of its activities and possible future plans.
Joint BASHH and Faculty Meeting 2012 The next joint meeting between BASHH and the Faculty is being held on Friday 20th January 2012 at the Royal Society of Medicine. The theme for the meeting is ‘Recurring issues in Sexual Health‘ .
Systematic Review of Induced Abortion and Women’s Mental Health Published The world’s largest, most comprehensive and systematic review into the mental health outcomes of induced abortion was published yesterday by the Academy of Medical Royal Colleges. The review concludes that having an abortion does not increase the risk of mental health problems. The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.
Should all nuns take the pill?
This was some of the media’s interpretation of an article published at The Lancet – Early Online this week. Britt and Short describe the well known health risks for nuns associated with their life of chastity, first documented in 1713. They also note that despite the roman catholic stance on not using any form of contraception apart from abstinence, dating from the Humanae Vitae document of 1968, this may be possible as the same document also states:
the Church in no way regards as unlawful therapeutic means considered necessary to cure organic diseases, even though they also have a contraceptive effect.
Treatment is freely available, but is limited to those who know their HIV sero-status. The HIV epidemic in the UK continues to grow, and the fraction of undiagnosed HIV remains frustratingly constant. The number of people living with HIV in the UK is estimated to be 91500 in 2010. There were an estimated 6660 new HIV diagnoses in the last year alone. In men who have sex with men, there were 3000 new diagnoses – the highest ever annual figure recorded in this risk group. An estimated one in four of all individuals with HIV infection remains unaware of their sero-status. Of those newly diagnosed, half were diagnosed with CD4 counts below 350 cells/μl, the current threshold for the initiation of antiretroviral therapy. Of the 680 people with HIV who died in 2010, two thirds had been diagnosed late.
and they suggest that:
The largest barrier rests with us, the healthcare providers: our own HIV testing prejudices need to be broken down. We need to engage commissioners to develop services and strategies to tackle HIV infection in our community. A key strength of the pilot studies to date has been the close cooperation between Sexual Health services and local primary and secondary care providers. We would urge you to work with your local Sexual Health colleagues. They will be keen to work with you to provide education, support, clinical expertise and guidance to keep this issue high on your local health agenda. Please engage with us, and Getting to Zero may be a feasible and very real vision here on our own doorstep.
This is the good news. The bad news is that at this crucial time, when the end may be in sight, we also hear that the one thing that will fuel the hoped for future is being cut off:
BMA News warns that Sexual Health is under threat (again).
As councils and private companies take control of NHS sexual health services, are they unnecessarily changing an open-access system that already works wonders? In the Report, sexual health organisations have expressed grave concerns and a number of clinicians give examples of difficulties already being experienced.
The Global fund to Fight AIDS, TB & Malaria has cut its latest round of funding. In its press release yesterday it states:
A sharply deteriorating economic situation, which is placing severe pressure on donor countries’ budgets, has prompted the Global Fund to revise its forecasts of available resources over the next two years and to take this difficult decision.