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The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of broad public importance. We traced the evolution of ACT-A's governance through publicly available documents and analysed it against three principles embedded in the founding mission statement of ACT-A: participation, transparency, and accountability. We found three challenges to realising these principles. First, the roles of the various organisations in ACT-A decision making are unclear, obscuring who might be accountable to whom and for what. Second, the absence of a clearly defined decision making body; ACT-A instead has multiple centres of legally binding decision making and uneven arrangements for information transparency, inhibiting meaningful participation. Third, the nearly indiscernible role of governments in ACT-A, raising key questions about political legitimacy and channels for public accountability. With global public health and billions in public funding at stake, short-term improvements to governance arrangements can and should now be made. Efforts to strengthen pandemic preparedness for the future require attention to ethical, legitimate arrangements for governance.

Sensorineural hearing loss (SNHL) related to chronic suppurative otitis media (CSOM) was studied to clarify the involvement of cholesteatomas in this context. Aim:to evaluate SNHL related to CSOM and its association with cholesteatomas, disease duration and patients’ ages. Methods:Retrospective analysis of 115 patients with CSOM with and without cholesteatoma submitted to surgical treatment. Inclusion criteria were active unilateral disease, normal contralateral ear and age below 60 years. Results:The average age was 26.3 years, 58 males and 57 females. The duration of ear disease was, in average, 12.4 years. The average threshold of hearing was 40 dB in CSOM ear and 22 dB in the normal contralateral ear (P=0.002). CSOM with cholesteatoma occurred in 78 of 115 cases. In the abnormal ear, SNHL was seen in 15 cases, being 6 cases of profound loss, that correlated with adjusted-age (P=0.003) and absence of cholesteatoma (P=0.01), but not with disease duration (P=0.458). Conclusion:SNHL occurred in 13% of the patients with CSOM, and was correlated with older age, but not with the presence of cholesteatoma or longer duration of ear disease.

The aim of this study was to evaluate fat absorption in HIV-positive (HIV+) patients in different phases of HIV infection using a 14C-triolein breath test. We distributed 47 HIV+ patients according to the 1993 Centers for Disease Control Revised Classification: 20 in Group 2 (A1 or A2) and 27 in Group 3 (B1, B2, A3, B3, or C). Ten HIV-negative healthy subjects comprised the control group (Group 1). All individuals underwent a 14C-triolein breath test. Parasitic infection was evaluated through three stool exams, including Cryptosporidiumand Isosporainvestigation. The median value of cumulative 6 hours' 14C excretion expressed as percentage of the 14C given as triolein was significantly higher in Group 1 (8.4%) than Group 2 (5.5%) or Group 3 (3.4%), p= 0.04 and p0.01, respectively. Fat malabsorption was found in 25% of Group 2 individuals, 52.6% of those without diarrhea in Group 3, and was correlated with CD4+ lymphocyte counts (p0.01). Fat malabsorption is a common feature in advanced stages of HIV infection, even in the absence of diarrhea and is also present in asymptomatic HIV+ patients. These findings suggest that malabsorption is an early event in HIV-infected individuals and is correlated with the degree of immunosuppression.

Discusses an editorial in 'The New England Journal of Medicine,' in which Marcia Angell questioned the ethics of a study in Uganda that monitored, and failed to treat, several hundred HIV-positive people. Urgent need for drugs and vaccines which fuel such clinical trials; Ethical conduct guidelines set forth in the Helsinki Declaration; Discrimination between patients in industrialized and developing countries due to economic considerations.

de Lima e Costa M F F (Grupo de Pesquisas em Epidemiologia, Universidade Federal de Minas Gerais, Av Alfredo Balena 190, 30. 130, Belo Horizonte, Minas Gerais, Brazil), Oliveira M R, Oliveira E I, Paulino U H M, Greco D B, Chiari C A, Guimaraes M D C, Proietti F A, Antunes C M F and Munoz A. Factors associated with AIDS and AIDS-like syndrome among homosexual and bisexual men in Minas Gerais, Brazil, International Journal of Epidemiology 1990, 19: 429–434. A case-control study to determine factors associated with AIDS andAIDS-like syndrome among homosexual/bisexual men was conductedin the State of Minas Gerais (Brazil). Eighty-three per cent (45 patients) of all AIDS/AIDS-like syndrome cases in homosexual/bisexual men reported in Minas Gerais between February, 1986 and June, 1987 were compared to 133 seronegative controls seen at the same clinic. Blood samples were tested by ELISA and confirmed by Western blot. Sex with men from the USA, sex with someone who developed AIDS, number of male partners (≥ 100 lifetime), age (≥30 years old) and ethnicity (white) were independently associated with AIDS/AIDS-like syndrome (Odds Ratios = 5.5, 4.3, 3.9, 3.5 and 2.7, respectively). Thirty-nine per cent of cases and 44% of controls reported bisexual activity during the previous two years. From these, a high proportion reported anal intercourse with women in the same period (53% of bisexual cases and 33% of bisexual controls). Bisexual men had more male partners than female partners in the previous two years (median male partners = 20 for cases and five for controls; median female partners = three for both cases and controls). This explains in part why the epidemic has increased more rapidly among men then among women in Minas Gerais, despite the large proportion of bisexuals with the disease.