Important note: Information in this article was accurate in October 2000. The state of the art may have changed since the publication date.The XIII International AIDS Conference, held July 9-14, 2000, in Durban, South Africa, was praised by participants for its focus on inclusion: of delegates from resource-limited countries, of community representatives, and of women. The presence, voices, and experiences of African women in particular set the Durban conference apart.
The UNAIDS "Report on the Global HIV/AIDS Epidemic," released just prior to the conference, announced that of an estimated worldwide total of 2.3 million people who died of AIDS in 1999, over half (1.2 million) were women. A staggering 82 percent of the 15.7 million women living with AIDS live in sub-Saharan Africa, according to the document.
A major focus of presentations, conversations, and protests at Durban was the issue of access to medications. Here women were cast in a strange light, somewhat marginalized once more. Access to antiretroviral treatment was portrayed generally as a developing world issue, but with no consistent focus on the needs of women. Many of the access discussions centered around prevention of mother-to-child transmission (MTCT). This issue, of course, directly impacts and involves women. Yet women's advocates repeatedly expressed concern that women are being viewed as vessels for treatment and transmission, rather than people in need of treatment themselves.
Access discussions also addressed women's persistent under-representation in research studies, particularly those documenting the effects of antiretroviral therapy and other treatment regimens. In resource-limited countries, access to healthcare for HIV and all other medical conditions continues to be a significant barrier for women, who are often last in line for limited family funds allocated to clinic visits and medicines.
Informed consent emerged as not only a vaccine-trial issue, but an issue relating to additional aspects of women's health. Other discussions addressed the right of HIV-infected women to have children (an issue of concern primarily in wealthy Western countries), and the right to limit childbearing (in resource-limited settings). Sex trafficking and the commercial sex trade continued to be major topics in terms of HIV transmission routes, though the human rights dimension of commercial sex was not the focus here.
Despite the African venue, and despite continued dialogue about male circumcision as an HIV prevention strategy, data and discussions on female genital mutilation were noticeably absent. Several researchers linked reproductive rights with the larger issue of the status of women, a theme reinforced by the many women delegates from around the world who shared their stories about battling stigma, blame, and repressive cultural norms.
This report summarizes only some of the many important discussions that went on in Durban during that busy week in July.
The success of the United States and other wealthy countries in dramatically reducing mother-to-child transmission has led to fervent efforts to implement workable MTCT prevention strategies in resource-limited countries. "We don't need a vaccine to solve this problem," said Allan Rosenfield (Columbia School of Public Health, New York) in a politically and ethically charged symposium keynote on vertical transmission of HIV, a topic that received much attention at the conference. "The issue here is inequity. We now have effective treatment in the US to bring transmission rates down to 5 percent, but not here in South Africa."
(Editor's note: Clinical aspects of mother-to-child transmission are discussed at length in Researchers Struggle with Complex Nature of Mother-to-Child Transmission of HIV in the October 2000 issue of IAPAC Monthly.)
Antiretrovirals and women's participation in MTCT prevention programs
While no major new findings about antiretrovirals and MTCT were unveiled at the conference, scientists from several countries reiterated the apparent efficacy and safety of short-course oral zidovudine (AZT) in late pregnancy [abstracts TuOrB354, TuOrB355, LbOr1] and the even more cost-effective one-time administration of nevirapine during labor [abstract LbOr2]. The nevirapine intervention, estimated to cost about US$4 per mother/child pair, was hailed as a potentially substantial weapon in slowing the spread of HIV, especially on the African continent.
Questions persisted about the long-term impact of in vitro antiretroviral treatment for uninfected children, as well as implications of short-term therapy for mothers. "The ethical consideration," said Rosenfield, "is that the short course of AZT preventive therapy uses the woman's body to confer treatment to the child, but gives no benefit to the woman. The short course therapy might increase viral resistance to drugs in the woman. If [she] never [gets] any other treatment, this is not important. But if she does, we may be increasing viral resistance to treatment. One thing we don't want to do with MTCT is make the woman's condition worse while reducing transmission. And I would say we don't have enough information on that."
Several researchers presented data showing that, even where antiretrovirals were offered, recruiting women to participate in MTCT programs was problematic. Researchers from Brazil, Botswana, Rwanda, Zambia, and Thailand all presented attitudinal data on significant barriers to women's participation in MTCT programs [abstracts MoOrD202, MoOrD207, WeOrC548, WeOrC550, WeOrC551, WeOrC552, WeOrC553]. Problems cited included: low quality of prenatal care; prohibitive cost of HIV diagnostic tests; fear of HIV-positive result and consequent stigmatization; inadequacy or unavailability of counseling; antenatal care initiation/testing too late in pregnancy to begin therapy; mobility; and refusal of husband or other family members. These results from a diverse range of countries indicate that reducing the cost of drugs is only part of the battle to stem MTCT worldwide.
"The core issue is poverty," Rosenfield said. "Were we to have access to drugs today, we don't have the infrastructure to deliver them in many places." His suggestion that governments reallocate military expenditures toward healthcare drew applause from the packed hall.
Breast milk: lifesaving or life-threatening?
A debate session on breastfeeding and HIV highlighted divergent opinions on this complex and controversial issue. In this session and others, participants reported that healthcare providers are unclear about what information to give HIV-infected women. Both presenters and audience members at the debate session articulated passionate cases for and against recommending that HIV-infected women breastfeed exclusively. (The supplementing of breastfeeding with formula, cereal, other solids, juices or other drinks, or even water is considered "mixed breastfeeding.") There was a clear division in opinions according to which socioeconomic setting each speaker represented, and no clear consensus was reached.
Countering current recommendations against breastfeeding for HIV-positive women, presenter Anna Coutsoudis (University of Natal, Durban, South Africa) and many participants from resource-limited countries weighed in resoundingly for the promotion of exclusive breastfeeding. Citing research that she had conducted in South Africa's KwaZulu Natal, the conference's host province, Coutsoudis presented a case for counseling HIV-infected women to breastfeed exclusively for six months, with rapid weaning thereafter.
Coutsoudis stressed that her recommendations were based on a definition of "exclusive breastfeeding" that included no other food or drink for the infant. A major challenge is that exclusive breastfeeding rates are low across virtually all world cultures, and, according to Coutsoudis, are lowest in sub-Saharan Africa. Most women around the world supplement breast milk with other liquids and solids.
The results of Coutsoudis' study showed that women who exclusively breastfed had a significantly lower risk of transmitting HIV to their infants than did women who practiced mixed breastfeeding, and that women who exclusively breastfed had similar rates of transmission to women who never breastfed [abstract LbOr6]. Mothers were not assigned to a study arm, but chose their preferred method of feeding. If they chose breastfeeding, they were counseled to exclusively breastfeed.
Mixed breastfeeding, explained Coutsoudis, introduces allergens and foreign contaminants, causing irritation of the gut mucosa, which is hypothesized to increase the risk of HIV transmission from breast milk. Exclusive breastfeeding promotes the development of beneficial microflora which reduce intestinal pH and limit infections, she said, and may facilitate gut maturation and closure. Because babies nurse frequently, exclusive breastfeeding most likely also reduces the likelihood of engorgement, mastitis, and nipple cracking, all risk factors for breastfeeding transmission. Coutsoudis furthermore asserted that the emotional bonding that is believed to result from breastfeeding is especially important for HIV-infected women and their babies.
Finally, she warned against the potentially disastrous "spillover effects" from a policy of promoting formula feeding in high HIV incidence countries. If artificial formulas are introduced to disadvantaged communities, children of other mothers who adopt this feeding practice may be placed at greatly increased risk for diarrheal and respiratory diseases due to contaminated water sources. Nutritional deficiencies may also occur if women cannot afford enough formula.
Many audience participants from Africa weighed in on the pro-breastfeeding side of the debate, including Conference Chair Hoosen Coovadia, a South African pediatrician. "Giving formula to women in developing countries is not an option," he said, naming two reasons for his assertion: the cost is prohibitive, and formula feeding is often culturally inappropriate. Coovadia said that women in poor communities who bottle feed might be stigmatized as having HIV, and as being bad mothers. "After all the counseling and testing, women still choose breastfeeding," he said. "We need to make breastfeeding safe. That's the only option."
Other audience members agreed. One participant asked about the feasibility of pasteurization. (At other sessions, some promising data was presented on the use of solar generators to pasteurize milk [abstract LbPp122] and on the use of alkyl sulfate microbicides to inactivate HIV in milk [abstract LbPp123].) Others suggested changing the focus to better care for the pregnant and breastfeeding woman to reduce her viral load and thereby lower the risk of transmission. Several speakers called for more exploration of antiretroviral prophylaxis for breastfeeding infants and their mothers.
The prevailing message, however, was that the route to lowering MTCT transmission in resource-limited settings is not obvious at this time. Various factors combine to create a host of unanswered questions. For example, one African woman asked, "What should be done in rural developing areas where testing is not available and women don't know their [HIV] status?" No clear response emerged.
When Mary Glen Fowler (US Centers for Disease Control, Atlanta) presented the counterpoint to Coutsoudis' case, she articulated some of the issues that make the breastfeeding debate so difficult to resolve. Although she was a supporter of breastfeeding, Fowler said, she felt that the data on the protective effects of exclusive breastfeeding were too inconclusive to recommend breastfeeding to HIV-infected mothers in the face of the known fact that breast milk can transfer the virus. (A Kenyan study presented later in the conference showed that breastfeeding may also be associated with a higher risk of maternal mortality [abstract WeOrC495].) Fowler also focused on what she termed the "huge burden" of attempting to convince women to exclusively breastfeed.
Fowler argued that exclusive breastfeeding is still under-studied, and that all of the studies to date had serious limitations. She advocated that the efforts of the international community be spent on proven methods of preventing mother-to-child transmission. "The current focus should be on implementing short-course antiretrovirals, while continuing to study exclusive breastfeeding," she said.
Several audience members agreed with Fowler. A US pediatrician was adamant that women who did not transmit the virus to the infant in utero or intrapartum be counseled against breastfeeding. "We know breastfeeding can transmit the virus. We want a non-infected infant!" he said. While many people nodded at his words, their facial expressions reflected the confusion surrounding this debate.
Obtaining truly informed consent across cultural, language, age, and gender gaps continues to be one of the health care community's greatest challenges. When people are implementing programs or conducting research cross-culturally, the same prevailing wisdom that demands patient rights, human rights, and informed consent also dictates that the cultural norms of the participant community not be violated. Most would agree that researchers and medical personnel should not come to a community and demand that it conform to their ethical standards and moral constructs. However, in the case of marginalized members of societies, including women and children, how to best respect cultural norms is debatable.
Suneeta Krishnan (University of California, Berkeley, USA, and Swasthya - A Community Health Partnership, Sringeri, India) presented an illustrative case study from her ethnographic work on women's vulnerability to HIV/AIDS within the context of marriage in the southern Indian state of Karnataka [abstract WeOrD505]. She described a case in which, after a pregnant woman was tested for HIV, the physician disclosed the woman's HIV-positive test result to her husband, father, and parents-in-law, but not to the client herself. The family debated whether she should have an abortion. "The woman was dealing not only with her HIV status, but trying to get some input into the decision on the pregnancy," said Krishnan.
It could be argued that the community norms were upheld in this example, in that the decision was regarded by that community as rightfully that of the family, with the male members having the most power. In a symposium on ethics in HIV vaccine trials, Graham Lindegger (Natal University, Pietermaritzburg, South Africa) addressed this potential conflict between respecting the rights of a community versus those of an individual woman [abstract ThOrE652]. Lindegger will be involved in upcoming HIV vaccine trials in the South African province of KwaZulu-Natal.
"Cultural sensitivity has been called for in many forums and documents," said Lindegger, "but its meaning is often ... unclear." He cited one definition which listed the components of cultural sensitivity as using semantic appropriateness, understanding the cultural context, and not intervening in any way that contradicts cultural norms. However, if trials fail to challenge detrimental and unjust cultural norms, then they run the risk of violating the principle of "first do no harm," he suggested. He also raised questions about deciding who represents the community, especially in cultures where women and children are traditionally disenfranchised.
Lindegger acknowledged that imposing standards of informed consent might be equivalent to imposing Western notions of autonomy and individualism into participant cultures, which might operate more by the principles of collective decision-making. "This has complex implications for the issue of informed consent. Who should consent for the participant in trials? In Western societies, we say it is absolutely the individual, but in cultures which practice collectivism, one may argue inclusion or even substitution of others, usually family members."
In spite of recognizing societies within their South African study population which do incorporate principles of collectivism, Lindegger and his colleagues have decided that "universal first person consent should never be ignored in clinical trials." They have decided that in some situations it might be appropriate to "invite significant others and the community to participate but only with explicit consent of the person involved."
Lindegger concluded, "We would like to avoid the extremes in informed consent ... of ignoring cultural sensitivity and of accepting cultural norms as unquestionable."
A Kenyan woman in the audience agreed. "I'm uncomfortable with this putting culture first in scientific research. As an African woman, I know that if you're not the power broker, you are not treated well. The community elders will not make decisions in favor of women and children."
Most audience members seemed to concur. As long as societal inequities such as discrimination against women exist, the only viable approach to informed consent seems to be to place the needs of the individual first--even before those of the community as a whole.
Kathleen Squires (University of Alabama at Birmingham, USA) opened her keynote speech for a symposium entitled "Gender Issues in Disease Progression" by asking, "Is HIV different in women?" She raised the question of whether differences in survival by gender were actually due to differences in access to care. Two trends that are emerging in the research, said Squires , are gender-based differences in the natural history of the disease as measured by viral load and differences in reactions to antiretroviral therapy.
Squires cited several studies showing that significant differences between men's and women's viral loads at seroconversion did not correspond to differences in the length of time until the onset of AIDS or until death. "Despite lower baseline viral loads, there is little evidence of slower rates of progression; most studies show no difference," said Squires. "What are the implications of this for treatment?"
Viral load and CD4+ counts are markers for when to start antiretroviral therapy, and these markers were established based on studies whose subjects were almost exclusively male, Squires said. The two sets of guidelines in use in the United States do not make gender-specific recommendations on when to start therapy. "If differences in viral load are transient and most pronounced early in the disease," said Squires, "it may not impact treatment." But she went on, "Should monitoring of CD4+ cell counts be more frequent for women early in the disease?"
Squires noted that this issue has implications for who participates in clinical trials. Women may be excluded from studies because of their lower viral load at early stages of the disease.
Squires advocated for more pharmacokinetic research on gender differences in absorption, blood flow, weight, and hormone changes. She noted that enzyme differences by gender have been shown to affect how drugs used in treating depression are metabolized. She called for a closer look at toxicity and weight, and also posed the question of whether changes in hormone levels during menses, pregnancy, and post-menopause might affect metabolization, drug-drug interactions, and other factors.
Squires' primary message was a call for the inclusion of women in more research studies. "Viral load may be lower in women early in the disease," she said, "but the mechanism is unknown. HIV-infected women must be adequately represented in pathogenesis-based studies and clinical trial development to definitively answer the question."
"Initial HIV-1 RNA level has been shown to predict progression to AIDS in men, but this has not been well-studied in women," agreed Timothy Sterling (Johns Hopkins University, Baltimore). Sterling reported that the results of a longitudinal study of injection drug users could be used to argue that "viral load at seroconversion in women does not predict progression to AIDS" [abstract TuOrB402]. Initial viral load did correlate with disease progression in the men in the study, which was conducted in the United States. There was no overall gender difference in time to AIDS. "Viral load cutoffs in current guidelines result in sex-based differences in eligibility for AIDS treatment, and the use of viral load cutoffs needs to be re-examined, especially in early stages of the disease," concluded Sterling.
In a study of HIV-infected adults in Zambia, Marie Quigley (London School of Hygiene and Tropical Medicine) found differences between men and women in HIV progression [abstract TuOrB401]. Participants were enrolled in a randomized trial for tuberculosis (TB) preventive therapy. Factors such as TB treatment arm, education, and crowding had no effect on disease progression. There was no significant difference in median CD4+ count by gender, although, when stratified by age, women under age 25 had slightly higher median counts. "For baseline CD4+ greater than or equal to 200, women had higher mortality rates than men, and faster CD4+ decline than men," concluded Quigley. Women had a shorter survival time than men, despite similar baseline CD4+ levels. (The study did not measure viral load.)
Wafaa El-Sadr (Harlem Hospital Center, New York) asserted that evidence of inferior outcomes in antiretroviral therapy for women largely reflects differences in access to care. El-Sadr and colleagues assessed risk of progression of HIV disease or death among patients enrolled in randomized studies in a US clinical trials network over the last decade [abstract TuOrB403]. While the analysis showed significant differences in disease progression by type of antiretroviral treatment and history of intravenous drug use, no differences were found between men and women across the studies and over time. CD4+ count was found to be a significant predictor of disease progression in both genders.
Although invasive cervical cancer has been considered an AIDS-defining illness in countries with advanced healthcare programs for several years, the connection between HIV and cervical dysplasia in resource-limited countries has remained unclear. Hugo DeVuyst (University of Nairobi, Kenya) speculated that studies connecting HIV-1 to invasive cervical cancer in developing countries have been inconclusive because "women are dying of other diseases first."
DeVuyst presented preliminary data from an ongoing study in Nairobi, Kenya, in which women attending a family planning clinic are screened for sexually transmitted diseases (STDs) and cervical lesions [abstract MoOrB234]. These results show a correlation between high-grade cervical lesions and HIV infection. DeVuyst underscored the likelihood that HIV infection is contributing to the already-high rates of cervical cancer in Kenya and other resource-limited nations.
A 1999 HIV/STD prevention study in Harare, Zimbabwe, found abnormal cervical cytology for 24 percent of HIV-infected women versus 6.4 percent of uninfected women [abstract MoOrB232]. Researchers found no status differences in terms of sexual behavior, and were unable to determine whether HIV infection or cervical neoplasia occurred first in study subjects.
Results of a prospective case-control study in the Ivory Coast were reported by Edith Boni-Ouattara (US Centers for Disease Control and Prevention Project Retro-CI, Abijan, Côte d'Ivoire) [abstract MoOrB233]. The study found only a slight difference in incidence of stage III or IV cervical cancer in HIV-infected and -uninfected women, but found that women with confirmed cancer in the HIV-infected group were younger. "Cervical cancer was associated with HIV infection for women under 40," said Boni-Ouattara.
Presenting African researchers advocated for increased availability of cervical cancer screening for HIV-infected women in resource-limited countries, but some in the audience expressed skepticism. DeVuyst acknowledged that spending scarce resources on screening is controversial because women may be dying from other causes first. Some symposium participants suggested that, in light of the evidence, limited screening resources should be used for younger women in HIV-endemic countries, and for women known to be HIV-infected.
Catherine Hankins (Montreal Regional Public Health Department) said that Canadian researchers are currently testing the efficacy of self-administered swabs (versus practitioner-administered swabs), a possible method of reducing screening costs. Hankins presented results of a study which found that the persistence of the human papilloma virus was associated with CD4+ counts of greater than 200, and that oral contraceptives seemed to have a protective effect [abstract MoOrB235].
Jan Keller (Johns Hopkins University, Baltimore) came to similar conclusions in her presentation on the recurrence of cervical dysplasia in HIV-infected women after cervical excisional treatment [abstract MoOrB237]. Keller reported that she and her colleagues found no significant association between CD4+ counts and abnormal follow-up after excision, but that detectable HIV-RNA and higher mean HIV-RNA levels were associated with recurrent cervical abnormality. Keller stressed the importance of antiretroviral therapy for managing cervical dysplasia in HIV-infected women.
Unfortunately, no innovative female-controlled STD prevention mechanism was unveiled in Durban. No female-controlled method available or in the works so far appears to have the cost-effectiveness or disease-prevention-effectiveness of the male condom. However, speakers from around the world reiterated the need for more choices on behalf of their female clients, especially young women with inadequate negotiation skills, commercial sex workers, and women who are victims of violence at the hands of male partners.
The female condom
Several conference sessions explored the current use, satisfaction, and cost-effectiveness of the female condom (FC). Some studies reported surprisingly high usage rates, some disappointingly low. In general, the consensus among users of the female condom seems to be that the device, though imperfect, is a valid addition to the potential arsenal of protection against HIV and other STDs.
A 1999 acceptability study on the female condom enrolled 2,453 women in Brazil. The women, who were public health clients in six cities, participated in a 90-day longitudinal study which found the acceptability rate to be an encouraging 70.1 percent.
As a result, a large-scale distribution and education program was begun in October, 1999. Two million FCs will be distributed annually in Brazil, with priority given to high-risk groups (sex workers, women with HIV infection, female drug users, women at risk of violence, and clients of STD/HIV/AIDS public health services). Commercial sex workers are reached through street outreach by non-governmental organizations (NGOs) that receive support from the national AIDS program.
Regina Maria Barbosa (Instituto de Saúde, São Paulo, Brazil) explained the mechanisms of distribution and education in the Brazilian study [abstract MoOrC133]. Women participated in discussion groups, were given three FCs, and then were given more supplies at a 15-day voluntary follow-up. A very high percentage of participants reported using the FC, and over 70 percent reported continuity of usage. NGO clients reported more consistent usage. The difference, according to Barbosa, could be accounted for by provider-client interaction. NGOs were more successful in encouraging women to return for follow-up sessions with healthcare counselors who helped them figure out how to overcome usage difficulties.
Barbosa noted that Brazil is characterized by a very low rate of male condom usage (only four percent). The Brazilian study found that 40 percent of the study population used a combination of the male and female condoms, and that the rate of protection among those combined users doubled, suggesting that combined use is an effective option.
A study of commercial sex workers in Thailand yielded less optimistic results [abstract MoOrC130]. Supanee Jivasak-Apimas (Siriaj Hospital, Bangkok) reported that participants were assigned to a male condom group or a male-and-female-condom group. The male-and-female-condom group used the FC as a second choice, usually when the client refused to use the male condom. Participants were trained in FC use. The study population was comprised of women 20-29 years old who averaged 21 commercial sex acts per week.
Women reported more tearing incidents with the male condom and more slipping with the FC. While women reported an overall satisfaction rate of 68 percent, only 33 percent said they would continue to use the FC after the study, even if they were able to obtain it free of charge. Most said they preferred using the male condom because of the following FC drawbacks: difficulties with insertion, excessive lubricant, itching, and poor fit. Study authors concluded that while comfort increased with use, the comfort level of the FC needs to be improved.
Zimbabwe's experience with the FC inspired an interesting discussion among conference delegates. Women's groups in Zimbabwe collected 30,000 signatures demanding access to the FC in that country. Steven Mobley (Populations Council, Washington, D.C.) reported on the dynamics of FC use in Zimbabwe one year following its subsequent introduction [abstract MoOrC132]. Results indicated that women who used the FC were usually in their mid- to late-20s. They had higher levels of education and higher socioeconomic status, and they were more likely to be female heads of households than women who relied on the male condom for protection. Twenty percent of FC users reported that they were not using the male condom before they began using the FC. For a segment of the Zimbabwean population, the FC seems to be a viable and important additional option.
Overall, the Durban conference yielded mixed reviews of the FC. Cost is a major factor, especially in comparison to the male condom. However, a cost-effectiveness study in rural South Africa showed promise of public healthcare savings with FC programs despite the higher cost [abstract MoOrC131]. Mitchell Warren (Female Health Foundation, London) reported that South Africa and Brazil are currently the biggest users and promoters of the FC [abstract MoOrC134]. Warren suggested that demand for the FC is continuing to increase, and that improvements on comfort levels are being made. He also said that studies were underway to explore the possibility of reducing costs by washing and reusing the FC (which is made of polyurethane, not latex), and that public-private partnerships might lower prices.
"Clearly [the FC] is not just a product--we're talking about programs," Warren said, stressing that FC promotion programs are most successful when counseling on usage is provided.
Megan Gottemoeller (Center for Health and Gender Equity, Takoma Park, Md., USA) presented on the current status of microbicide research. "Microbicides," she said, "are substances that can substantially reduce transmissions of sexually transmitted infections when applied to the vagina or rectum." She described current microbicide products as being similar to today's spermicides: they come in the form of gels, creams, films, suppositories, sponges, vaginal rings, and vaginal wipes.
Microbicides have several attractive features, said Gottemoeller, including low cost, over-the-counter availability, and the possibility of use without a partner's cooperation or even awareness. This would make microbicides particularly valuable to women who are unable to negotiate other forms of protection with partners. The protection expected from microbicides is "not as ideal as consistent, correct condom use," said Gottemoeller, but there are tradeoffs. In the public health schema, a lower efficacy method used with higher levels of consistency could offer the same protection as a high-efficacy product used inconsistently.
Gottemoeller reported a "dramatic increase in the last few years of products being investigated." However, a lack of funding has prevented products from moving from preclinical to phase III research. Large pharmaceutical companies are reluctant to invest in these products, Gottemoeller explained, because research on prevention methods is a lower priority. "There is a need for advocacy to increase US and European spending on microbicide research," she concluded. "There is broad-based demonstrable demand, and this could really impact this epidemic."
Lut VanDamme (Institute of Tropical Medicine, Antwerp, Belgium) reported disappointing preliminary results in research on the effectiveness of COL-1492, a nonoxynyl-9 (N-9) microbicide product. In four countries, commercial sex workers who used an N-9 gel showed higher rates of HIV infection than those using a similar but inactive lubricant. In her plenary presentation on the current status of microbicide research, VanDamme said, "I think this might be the end of N-9 as a potential microbicide." She added, though, that she remained committed to and optimistic about microbicide research.
(Editor's note: See Bob Roehr's article Microbicides 2000: Fashioning New Tools to Deter HIV Transmission from the June 2000 issue of the Journal of the International Association of Physicians in AIDS Care.)
The idea that male-to-female transmission of HIV is more likely because of anatomical and physiological factors was not news at Durban. Several presenters did, however, offer more information on the social and behavioral factors that might make women, and especially young women, more susceptible to the disease than their male counterparts.
Violence against women
In a session on violence against women, presenters told the stories of women who had been caught in the mass rapes of war zones, young girls and women involved in sex trafficking, and women who suffered violence at the hands of their intimate partners. All of these women are thought to be at increased risk for acquiring HIV.
In the cases of war rapes and the selling of young women into what amounts to sexual slavery, the connections to HIV transmission are clear. In other cases of violence against women, the hypotheses state that abused women are less likely to be able to negotiate condom use and are more likely to be raped. Forced sex can involve less natural lubrication in the vagina and can be rougher, resulting in more tissue damage to the vulva and vagina and an increased risk of HIV and other STD transmission. But research with abused women is extremely difficult, and researchers presenting at Durban continued to struggle to show conclusive connections between HIV transmission and intimate partner abuse.
In a session on how mobility and migration affect HIV transmission, Tep Mony (Cambodian Coordination of Action Research on AIDS and Mobility, Phnom Penh) discussed the particular dangers to women and girls victimized by sex trafficking from Vietnam to Cambodia. Women and girls from poor families are often deceived into making the cross-border journey, she said, by promises of legitimate work and money. They find themselves in sex work and debt bondage. "The migration process makes migrants vulnerable to sexually transmitted infections, HIV, and AIDS," said Mony. Compounding the problem, she added, is the Cambodian culture's willingness to accept men's visits to brothels.
Nadine France (World Health Organization [WHO], Geneva) reported statistics from a WHO project to address the needs of women and girls in Rwanda [abstract WeOrD562]. The project focused on improving access to health care and social services for women affected by war-related violence. After the widespread violence between warring ethnic groups in 1994, France reported, women who had been raped were "filling hospitals, dying of AIDS." In a 1997 survey, she said, 27 percent of Rwandan antenatal clients tested positive for HIV.
Rajesh Vedanthan (University of California, Berkeley, USA) reported increasing evidence in India of growing HIV rates in a population traditionally considered to be low-risk: married women [abstract WeOr564]. His study of married couples who requested HIV testing and counseling found that of 62 couples in which the man was HIV-infected, 74 percent of the wives were sero-concordant. Vedanthan and his colleagues were surprised to find that sero-concordance and women's reports of violence did not correlate statistically. Researchers speculated that there might be some reporting bias in the sample, since more men than women reported violence in their relationships. Sero-concordance was correlated with men's reports of marital violence.
Charlotte Watts (London School of Hygiene and Tropical Medicine) called for a broadening of the context of risk, moving away from the standard perspective that sex is mutually desired [abstract WeOrD560]. She recommended that prevention activities include gender role discussions and explicitly address violence against women. She asked workers in the field to promote partner communication when working with male clients, and to challenge men's expectations of sex on demand.
Multiple partner risk may be different for young women and men
A random community sample of 600 young women and men ages 13-24 in the Carletonville township near Johannesburg, South Africa, found that young women had higher HIV rates than their male peers [abstract WeOrD506]. Catherine MacPhail (Council for Scientific and Industrial Research, Auckland Park, South Africa) reported that the difference in infection rates could not be explained by differences in the subjects' ages when they first had sex, because the mean age for beginning sexual activity did not significantly differ between genders.
The higher female infection rate may be explained in part by differences in partner ages: young women tend to have relationships with older men. But MacPhail and colleagues think that biological factors and differences in the ages of partners only partially explain the gender difference in infection rates.
Men in the study were more likely to have more than four partners. But one notable finding was that among young women, the risk of infection was found to increase by 25 percent per partner, while for young men, the risk increased by only 8 percent per partner. "A greater number of partners increases susceptibility more for women than for men," said MacPhail, noting that this finding could have a profound impact on the formulation of prevention messages.
"Women cannot talk to their husbands about sex. Women have to have sex with their husbands, they are told by the elders. ... There is no way to get help [if you are sick or abused]. ... They will look at the bride price: you are married. ... The husbands go to the cities. To him [disclosing you have an STD] means you have been with other men. He is innocent. There is no discussion on that."
--Etta Dendere, participant in the International Community of Women Living with HIV/AIDS (ICW) Voices and Choices Project in Zimbabwe
"The man may be the transmitter of the disease, but the source is the woman. For example, if a well is poisoned and a man drinks from it and falls ill, people do not blame him. They blame the well."
--Comment from male study participant in India, as reported by Suneeta Krishnan (University of California, Berkeley, USA, and Swasthya - A Community Health Partnership, Sringeri, India) [abstract WeOrD505].
The news from Durban on women and HIV/AIDS is that gender inequity must be addressed. Women can transmit HIV to their sexual partners and to their babies. However, women are not merely vessels, but victims as well. More women than men are now dying of this disease.
Women are dying in part because they have less access to the world's resources. In families all over the world, speakers at the Durban conference told audiences, women's health is compromised when resources are low. They get less food and less medical attention. Women are stigmatized and oppressed in many ways that affect the spread of HIV. They are denied access to information, they are unfairly blamed for the spread of the disease, and they are forbidden to get help or to leave relationships in which they are at risk for infection. Women's health issues are afforded less research funding and women are not included in research studies in proportions relative to their participation in the epidemic.
This public health problem cannot be fully solved with better drugs or a vaccine. The international community working to stop the spread of HIV will need to attend to human rights issues, including gender inequities, in order to turn the tide of the epidemic. Where women do not have a voice, the silence surrounding this disease will never be fully broken.
Carmen Retzlaff, MPH, is a writer and public health educator based in Austin, Texas, USA (crchec@flash.net).
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