News 2006

Prevention

By Linda Villarosa

TORONTO -- Musa Njoko’s HIV diagnosis came with the news that she had three months to live. The doctor then instructed her to go home and say goodbye to her family, including her 2-year-old son. Ten years later, she not only survived, but also thrived, becoming one of the first women to disclose her HIV-positive status in her native South Africa. Still the singer and activist stressed that too much about HIV/AIDS and how it affects women and girls across the globe remains strikingly similar to a decade ago.

“I still see the same stats and hear the same messages,” said Njoko, 34, whose long braids brushed her shoulders as she spoke at the XVI International AIDS Conference in Toronto. “I am not male bashing, but all of the interventions are still targeted to men. We are the ones who are suffering; we are the ones in crisis.”

Njoko joined Melinda Gates, BET co-founder Sheila Johnson and others on a panel entitled “Women on the Frontline in the AIDS Response.” That event was the centerpiece of a day of activities highlighting both the plight and power of women in the world-wide HIV/AIDS pandemic.

Almost half of the adults living with HIV today are women, 17.3—over 2 million more than just five years ago, according to UNAIDS. Since 2004, the number of women and girls infected with HIV has increased in every region of the world. In sub-Saharan Africa, women and girls already make up almost 60 percent of adults living with HIV.

The theme of the day, and, indeed of the conference is that despite the alarming trends, women are more than victims. “I am not proud to be a woman living with HIV, but I also am not ashamed,” said Njoko. “It is women who have to take the lead to make sure that there are interventions that are empowering to us.”

The day’s events kicked off just after 7 a.m. with the first ever march for women officially endorsed by an HIV/AIDS conference. The gathering was lively and spirited, even at the early hour. Over 1,000 women, many carrying signs and most wearing bright gold T-shirts that read “Time to Deliver AIDS Action Now for Women and Girls,” snaked through the streets of downtown Toronto, chanting, singing and accompanied by an international collective of aboriginal drummers.

“We have got to let the world know that the lives of women matter,” said Dr. Helene Gayle, president of the International AIDS Society. “It is only with the involvement of women that we are going to have an impact on this pandemic.”

Gayle was part of an eclectic round up of pre-march speakers, including Rep. Barbara Lee (D) of California and a number of women living with HIV/AIDS around the world.

Later in the day, a group of about half dozen African American women gathered offsite at Toronto City Hall for an intimate, small-group discussion about how HIV/AIDS is affecting black women in America and what to do about it. In each of the past 15 international AIDS conferences, there has been little discussion of HIV among African Americans, particularly women. Those issues have generally been overshadowed by the scope and breadth of the epidemic in Africa and other parts of the world.

Medicine

By Alice Thomas-Tisdale

TORONTO -- Using a once-a-day protease inhibitor appears to work as well with some patients as with those using standard three-drug cocktails to control their HIV infection, said University of Nebraska Medical Center researcher Dr. Susan Swindells.

She presented her findings during a media briefing at the International AIDS Conference in Toronto, kicking off the Aug. 16 edition of “The Journal of the American Medical Association.”

Swindells' findings are important because they suggest "maintenance therapy with ritonavir-boosted atazanavir alone is a possible option because of low pill burden, once-daily dosing, safety, and unique resistance profile." Most antiretroviral agents must be taken twice-daily. Several, notably ZDV and the protease inhibitors saquinavir and indinavir, must be taken three times a day. A standard dose can range from one tablet twice a day (3TC) to three capsules three times a day (saquinavir). The regime is an important consideration because of other studies suggesting that the amount of pills and the frequency with which these must be taken adversely affect a patient's willingness to continue treatment.

Antiretroviral regimens help to maintain serum concentrations of the chosen drugs at levels high enough to suppress viral activity to low levels and prevent the development of drug-resistant viral strains. The rule of thumb for Americans diagnosed HIV+ is medications are started when the CD4 count is at or above 350 and the viral load is 100,000 or higher, or the patient has serious symptoms. When the CD4 count is between 200-349, treatment is considered. When the CD4 count is below 200, treatment or antiretroviral therapy is recommended.

Of the 36 HIV participants in the study, nine or 25 percent were black. "Matter of fact," said Swindells, "the first patient to sign up was an African-American woman from Omaha, Nebraska." To qualify for the study, participants had to have no prior virologic failure, a CD4 count less than or equal to 250 T-cells and other relevant factors.

Swindells explained: "The long-term adverse effects, expense, and difficulty of sustained adherence to multi-drug antiretroviral regimens have prompted studies of simpler therapies for human immunodeficiency virus type 1 (HIV-1) infection."

Therapy Regimen

What you need to know about the proposed maintenance therapy:

What to Start

Antiretroviral therapy with such agents as 3TC, ZDV, and the thrice-daily protease inhibitors saquinavir and indinavir

When to Start

When CD4 count drops below 350 and before it reaches 200

What to Change

Change treatment to simplified maintenance therapy with once-daily doses of ritonavir-boosted atazanavir

When to Change

24 weeks after sustained virologic suppression has been observed

For a complete report, visit www.jama.com.

Prevention

By Frankie Edozien

TORONTO -- As delegates to the XVI International AIDS Conference, walked the halls and talked of HIV prevention strategies, conversations invariably led to the recent study in Orange Farm, South Africa that found that circumcision had an astounding 61 percent chance of preventing female-to-male HIV infection.

One of the biggest donors to HIV/AIDS research, Melinda Gates, even touted circumcision during the opening ceremonies fueling the ongoing debate on its efficacy

That adult male circumcision could be a preventative procedure, permeated so many conversations that it was surprising to some that there was only one panel discussion on the issue among the myriads presented during the conference, held Aug. 13-18. Delegates reported that in Botswana, many men were lining up to get circumcised if it meant protection from HIV.

Kawango Agot, a researcher from Kenya, presented findings that concluded circumcision has “shown some protective effects for women and if it’s not helpful for women, it’s not helpful at all.”

She conducted two studies of men who used government facilities and were not in a controlled trial. “Forty-seven percent chose circumcision because of protection against sexually transmitted infections.” Her colleagues on the podium seemed to agree that the power of circumcision as a prevention tool is a forgone conclusion.

While international organizations are waiting for the results of two more studies before officially beginning to praise its benefits, Agot said there are 13 more studies going on in nine African nations. A study by Dr. Robert Bailey of the University of Illinois, Chicago is expected to be completed by 2007. His study in Kisumu, Kenya, began with nearly 5,000 people, but now has 2,784 subjects.

Dr. Douglas Schaffer of the Walter Reed Army Institute of Research said his study of residents in rural Kenya, where 77 percent never used condoms, showed that the procedure “offers a degree of prevention for men in the Rift Valley.”

Kyeen Mesesan, graduate student at the Yale School of Medicine, presented findings from a study in Soweto, South Africa, and concluded that if the male circumcision program was continued, 32,000 new infections could be prevented in 20 years.

“Circumcision is already having a tangible effect on the epidemic there,” she said but warned that “if risk behavior continued [among the newly circumcised] the benefit of the program could be diminished.”

Dr. James Kahn, professor, Division of Clinical Epidemiology, Institute for Health Policy Studies at the University of California, worked on the much-talked about South African random control trial that concluded that 61-percent preventive efficacy in adult male circumcision represents a cost-effective tool in prevention methods.

At a cost of $55 per adult male, the cost-saving in HIV treatment could be $8,000 or more. Four of the five experts who spoke to delegates at the conference were white researchers from the United States. A point not lost on the multicultural delegates. I’m happy to see your face up on the panel,” Nesha Haniff, a Jamaican researcher, said to Agot.

“How can you roll out a plan that tells us to say to black men what to do with their penises from research that’s from a predominately white and western sector. It’s impossible,” she said.

Haniff said later: “It is my great frustration that the lead scientists on almost all these projects are western, white and almost always predominately male. Our culture and perceptions and realities are constantly being left out and structured like a purely logical scientific problem.

Many questions were left unanswered. Details on the science itself on why circumcision is preventive were sketchy. “I want to be able to explain why it works. They haven’t told us that. Just that it works,” Haniff said.

Some social scientists lamented the fact the studies failed to consider the cultural implications of asking black African men to consider circumcision. Others said scientists were confusing the issue by suggesting condom use instead of the surgical procedure.

“We are saying that if the studies conclude that it is beneficial, it has to be incorporated into the whole spectrum of prevention strategies, including condom use, abstinence, faithfulness, other risk reductions, needle exchange and everything else,” Agot said.

Frankie Edozien is a reporter for the New York Post.

Resources

By Erv Dyer

TORONTO -- For more than a decade, Anne Marie DiCenso has committed herself to helping inmates get HIV counseling and treatment. Having lost a friend and a former inmate to the virus, she is passionate about taking education and treatment efforts to jails and detention centers.

Not everyone shares her passion. It is tough, said DiCenso, because funding is difficult to come by. There is not a lot of sympathy for convicts and “it is not a hot, sexy topic” that draws many benefactors.

To make ends meet, occasionally, DiCenso, a director of Prisoners with HIV/AIDS Support Action Network, or PASAN, accepts a grant from a pharmaceutical company.

It’s not the easiest decision, but it’s one way that DiCenso said she believes she can continue the services that are critical to making a difference.

PASAN, which primarily allows inmates to make collect calls to obtain information and share their concerns on HIV, has a budge of about $400,000 a year. About 10 percent comes from pharmaceutical companies, she said.

But, PASAN is not the only organization that struggles with having to use funding from drug companies. It’s always been an uneasy alliance.

Drug companies have deep pockets. Non-profit organizations, especially in a climate of shrinking public funding and higher rates of HIV infections, do not.

So, it becomes complicated because nonprofits must often hold their hands out to the very companies they often criticize regarding medicine costs and access.

DiCenso said PASAN only accepts drug funding without strings attached. That’s the compromise that she feels does not infringe upon her programming.

The group last accepted $5,000 in funding a few months ago. The money was used to support a newsletter, a publication they can’t use government funds to produce.

Increasingly, PASAN uses drug company grants to fund the doctors and nurses who work with the group and agree to talk to inmates about counseling and prevention of sexually transmitted infections.

It’s to remain vigilant, said DiCenso. “These companies make a lot of money and it’s difficult to see people make money and folks still are not getting access. So we have to be watchful.”

The Black AIDS Institute, the organization that produces The Drumbeat Project and Ledge magazine, also grapples with the matter. In fact, seven pharmaceutical companies, including Abbott Laboratories and GlaxoSmithKline, provided support for the daily newsletter that BAI produced during the XVI International AIDS Conference.

The institute has accepted funding from drug companies since its inception. Phill Wilson, executive director of the institute, said he believes developing a relationship with the pharmaceuticals is key to one of its primary goals: to advocate for treatment. One of the ways to do that, said Wilson, is to know the companies that supply the drugs.

To handle what could be tricky association, the institute always discloses its funding sources and refuses to accept grants that interfere with the content of the message.

Is there a conflict of interest when the institute needs to be critical the pharmaceutical industry?