Important note: Information in this article was accurate in September 2001. The state of the art may have changed since the publication date. IAVI Report - July / September 2001
Dorothy Mbori-Ngacha is a pediatrician and senior lecturer at the University of Nairobi, with training in epidemiology from the University of Washington. She has been involved in mother-to-child transmission and perinatal trials for most her research career. Mbori-Ngacha is also senior clinical advisor to the Kenyan AIDS Vaccine Initiative in Nairobi, which is now conducting Phase I studies HIV vaccine studies through an IAVI-sponsored collaboration between the U.K.'s Medical Research Council, Oxford University and the University of Nairobi.
In Kenya the HIV prevalence in men and women is similar. But in young people between 15 and 24, there is a big gap—many more women are infected. In towns with high prevalence the risk to young women is 3 times higher than for young men. Since the epidemic in women starts earlier, they are dying very young.
This has to do with the status of women. Because of poverty, young girls have older partners, who are more likely to be infected. Early in the epidemic many men felt that their risk was lower with sexually naive partners. So older men targeted younger women.
Young women who are poor, who are less educated, don't have a voice. A poor family with a boy and girl may push out the girl and encourage the boy to go on with school. As we say in our part of the world, women don't belong to the family. A woman will get married and go off to another family.
In our work, we see that women tend to be at risk not because of their own behaviors, but the behaviors of their partners. You don't have to have multiple partners—one is enough, particularly in high prevalence areas. Many women know that their partners have other partners. But he is your provider, so it is very difficult. Our society says, oh, men are like that. Just accept it. What's the big deal? But now, women can stay in one relationship and still get AIDS.
We felt very strongly that we wanted to include women because they are at such high risk. If we have a vaccine that hasn't been tried in women, how are we going to translate that for women in a timely way? We lobbied hard at our national regulatory body.
But we didn't get many women volunteers—only 2 out of 18 participants. We have our volunteer who went public, Dr. Pamela Mandela. But she's not a typical woman. She's well-educated and has a lot of confidence in herself, which your typical Kenyan woman does not. Many women don't have that capacity to make the decision themselves. They said, I might be interested but I need to discuss this with my partner, or with some experts. For the men, once they've decided, it's done. They may choose to inform their wives or partners, but the decision is theirs.
Another thing that came up for women is the fertility issue. Women need to be clear that they will not have a baby in the next year and a half. That makes many of them think twice.
For the Phase I trial, we looked for well-educated people who will grasp the science, who can give informed consent. They are role models, so other people will say, later on: if the doctors are doing this, it must be alright.
Going to the next level is really going to be a challenge. We will need to have education targeting women. Maybe we can mobilize communities to see this as something that both men and women can do for the epidemic.
Now it's 18. But many people are not happy with 18. They say it is so young. Yes, they are young, but they are having sex and getting infected.
Other people say, what about including adolescents? This would open a whole different set of issues. How do you get consent?
Who would give consent? If you ask the parents, they would say, yes I would want to know if my child was involved in this. Even with contraceptives, parents say they want to know if their daughters are using contraceptives. The daughters say, it is none of your business.
The other question is, would a vaccine make adolescents feel that all is well and they can go on with risk behaviors? Adolescents think they are invincible, that nothing can happen to them.
I would leave the age limit at 18, because it avoids the issues of minors and trials. Maybe you would miss something, though, because people say there is a little bit of a biological basis that young women are at greater risk of acquisition. The vaginal canal is not fully developed, they get STDs, they don't have access to treatment. So they have increased vulnerability.
We are just beginning to put into place youth-friendly centers where you find peers to talk to and staff who offer you services without trying to "convert" you. When young women went to traditional family planning clinics they would find someone the age of their mother who would probably say, "What does a nice young girl like you want contraceptives for?" Many youth just go to a pharmacy and buy the pill across the counter.
At our teaching hospital we have a walk-in clinic for adolescents. There are a couple of others, but not many.
Very few. It's only now that counseling and testing is becoming a big thing. At our walk-in clinic, people can get information about AIDS, they can be tested. In the rural areas, the government is committed to scaling up. Work elsewhere tells us that knowing your status translates into very good prevention strategies, because many people who are negative then change their risk behaviors.
But the number of people? Low, low, low.
We have places in Kenya where the EPI (Extended Program for Immunization) is very successful—people go there and have their babies immunized. Then there are places where they don't.
We did some research on why women don't bring their children for measles immunization. It turned out that many people believe measles is a milestone, a rite of passage in a child's life—your child should have measles, because afterwards all will be well. So telling them that this vaccine prevents measles didn't have any pull. With this information the program could address those issues with the communities and highlight measles deaths, and emphasize that they are avoidable. Then the immunization rate came up.
What I'm saying is that we need to understand peoples' perceptions and expectations. Within Kenya there is a whole spectrum, from high to low vaccine coverage. Sometimes it's an access issue. But even where access is similar there are differences in vaccination rates. The social and cultural barriers have to be explored.
Mostly it's nevirapine at some pilot sites. The government is now trying to get nevirapine from the manufacturer so it's available country-wide.
But there are problems. Over half the women accept testing, but less than a third of those who test positive come back for the interventions. We are trying to understand this. Why would you not return, after going through this whole process, to benefit from what we promised in the beginning?
When women come to the antenatal clinic, their agenda isn't to learn their HIV status. They want antenatal care. They may get tested, but if it comes out positive, many aren't ready to deal with that. Many are afraid.
We are doing this within a rural setting where the person providing care for you might be your relative, your neighbor, might be from your same village. So many women don't feel comfortable coming forth for the treatment.
I think we did it backwards, in a sense. We should have mobilized the communities so they would support a woman in using antiretrovirals for preventing transmission or for not breastfeeding her baby. Right now there isn't enough support. Her mother-in-law will ask and visitors will ask, and it will be very difficult for her to justify why she's not breastfeeding.
It's big, it's really big. The issues are more than just finding the right drug. Now we have something tangible we can do. But women are not using it.
But this 40% has the potential to increase, because health providers have to change. It's not at all common to see men in prenatal clinics. The clinics need to invite men to come with their wives or partners; to initiate the dialog.
It helps when you introduce the topic of HIV testing to a couple together, and they take the test together. The outcome in terms of them taking up the intervention and the support the man gives the woman is much better this way. When you do it later it becomes very difficult for the woman.
It's going to be very complex. When you go for a vaccine you could say one of two things: you either take risks yourself or you're implying that your partner does. We've seen this at our MTCT sites. If a woman says she would like to be tested, her partner may ask, what have you been up to?
Why do you want to take the test?
It's almost like an admission of something. Or are you accusing me? There is a no-win situation.
I think the key is to say that this is good for the family. In MTCT we say in Kenya that pregnant women who go for HIV testing are good women because they want to protect the child. There are many issues with that approach. It promotes knowing her status just for the child, not because it is a good thing for the woman herself. But we used the feedback we got—that we as a society value our children and believe we should protect them.
In the vaccine arena, I think it will be similar, where you say vaccines are important to protect men and women for future generations. It has to be really thought through. People are always in denial about their own risk, or their children's risk.
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©2001. The IAVI Report.
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