Infection Rates Rising in Women
By Carla Garnett
Photos by John Crawford
On the Front Page...
Even with all the weapons heightened public awareness
campaigns, safe sex advisories, needle exchange programs,
treatments such as zidovudine (AZT), protease inhibitor "cocktails"
and most recently, highly active antiretroviral therapy
(HAART) deployed against the HIV/AIDS epidemic in two
decades, the disease is still winning, according to panelists at a
recent women's health seminar. Further, they point out, the
epidemic's relentless advance is no more increasingly evident than in
the world's women and children.
"The epidemic abroad is quantitatively so much larger than the one we face here...[the epidemic] is particularly intense in Africa," said Dr. Neal Nathanson, NIH associate director for AIDS research and one of four presenters at a recent seminar sponsored by the Office of Research on Women's Health.
State of the Epidemic
In his overview, "AIDS in Women: Epidemiology and Control in Africa, the Third World, and the United States," he said the estimated number of people living with HIV/AIDS by the end of 1999 was 23.3 million in sub-Saharan Africa and 920,000 in the United States. In Africa, prevalence and number of new cases are both increasing each year. In the U.S., 800,000 people are estimated to be living with HIV/AIDS; 300,000 of those can be considered to have AIDS already, according to Centers for Disease Control and Prevention classifications.
"When an epidemic becomes this big," Nathanson said, "usually it levels out and becomes endemic, but in fact the epidemic is still advancing...We are not getting on top of this epidemic from a public health point of view."
Another thing about the U.S. epidemic is that it has changed radically in terms of the population that is affected, Nathanson added, noting that heterosexual transmission is the primary mode of transmission in developing countries. "In the past in the U.S., it has been much more of a disease among men than women, although that's rapidly changing. It has become much more an epidemic of minorities, moving from a little more than a third to at least two-thirds of the population, and much more of a problem of women," who now account for at least one quarter of the epidemic and that number is rising.
"The good news is that HAART is quite effective," he said, "resulting in a remarkable drop in the death rate, which is now plateaued at 50 percent of the peak 20,000 [deaths] in the last year, as opposed to the 40,000 a few years back."
He mentioned the epidemic's dramatic impact in Africa. Life expectancy which had been improving in sub-Saharan Africa has plummeted and "this is entirely due to the AIDS epidemic," Nathanson continued.
He did have some relatively good news from Uganda: A combination of social marketing, fear and concern stemming from the very high incidence of deaths and infections, and an acknowledgement that there is a lack of treatment, have all led to some safer sex practices, a reduction in partners, an older age of beginning sexual activity, and more use of condoms.
"As a result," he concluded, "there's been a rather remarkable drop in prevalence. That's a very important sentinel. [It indicates] there are ways one can put the brakes on the epidemic, even in countries with limited resources."
Still, he said, a much higher proportion of new infections and existing infections in Africa are among babies and young children. Postpartum infection is still high there, as well as a considerable amount of transmission via breastfeeding.
Preventing Mother to Child Infection
Taking up where Nathanson's talk left off, a firsthand account of "Recent Advances in the Prevention of HIV Perinatal Transmission" was offered by Dr. J. Brooks Jackson, professor and vice chair of pathology for clinical affairs at Johns Hopkins, who has spent 10 years conducting clinical prevention studies in Uganda.
The substantial progress made in preventing perinatal transmission by the United States paved the way for the recent successes in developing countries, he said. The number of HIV-infected women who deliver babies in the U.S. every year has been fairly steady at between 6,000 and 7,000 per year. Over the years, with the use of AZT and now combination therapy, the number of perinatally acquired HIV cases has dropped considerably from about 1,500 per year to "probably less than 300 infants born in 1999 with HIV," Jackson said. In contrast, an estimated 700,000 infants in developing nations will be infected with HIV by their mothers during delivery; the number of babies infected rises even further when counting transmissions via breastfeeding.
Although most of the preventive regimens used in this country are far too expensive about $800 per mother/child for AZT, for example to be adopted by developing nations, researchers supported by NIH and working in Uganda have been able to produce measurable results with other preventive therapies such as nevirapine a single dose of which costs $4 for each mother and each child, according to Jackson.
"While very successful here," he explained, "it's very difficult for governments in developing countries to be able to afford [an $800 regimen], where healthcare expenditures are typically $3 to $10 per person."
Saying that the search must continue for alternative therapies, he outlined six requirements for new treatments: they must be safe, feasible, simple, efficacious, inexpensive, and able to be delivered peripartum (when most transmissions occur).
Jackson concluded by reporting non-cost related obstacles to getting the therapy to pregnant women in some parts of Africa, including slowness of governments to license and distribute the drug; ignorance about the drug's benefits; and requirements that women first undergo testing and counseling, which is more expensive than the drug regimen.
"We think the nevirapine is safe and will be effective in preventing perinatal transmission," Jackson said, "and it is deliverable in sub-Saharan Africa and other resource-poor settings, but it does need to be translated into public health policy."
'Treatment in the Real World'
Dr. Victoria Cargill of NIH's Office of AIDS Research discussed "Treatment Issues and Challenges in Women," bringing firsthand experience from closer to home inner city Cleveland.
"There certainly have been gains in the epidemic," she began, "however, the survival advantage has not been as profound in certain communities, particularly communities of color. Drug resistance continues to be a real consequence of treatment. Being compliant with one's medication continues to be a significant challenge, and there are major gaps in medication access."
Explaining that "HIV in women reflects not just one epidemic, but overlapping epidemics epidemics of sexually transmitted diseases, alcohol and drug use, poverty and violence," Cargill explored several practical concerns often overlooked: some women's lack of knowledge about available treatments, their sometimes limited access to care, a mistrust of the medical establishment, and the competing needs of a woman's family and home life.
To illustrate her point about effective caregivers having to know a woman's life circumstances as well as her HIV status or what she termed "survival collides with HAART: treatment in the real world" Cargill described three HIV-positive women she had seen in her practice: A 52-year-old African American intravenous drug user addicted to heroin and crack cocaine, who in order to support her drug habit routinely fenced the hospital supplies she was prescribed and who had been subsequently dismissed from five previous practices; a 38-year-old Latina who had four daughters three of them already diagnosed with HIV and an abusive partner, was found to be 6 weeks pregnant and without money for housing; and a 15-year-old juvenile delinquent with a history of 10 sexually transmitted disease episodes in the last 2 years who claimed, upon being informed of her HIV-positive status, "I don't need no damn drugs."
In conclusion, Cargill shared several lessons she has learned from treating such women: Learn to accept a less-than-perfect solution, assume nothing, and above all, know and respect your patient's needs.
"Therapy in this setting requires a lot of creativity," she said. "We have to be a partner with our patient. What may be top on my list is starting therapy; what may be top on her list is having housing and food for her children. We have to meet in the middle somewhere."
'Stealthy Prevention' Needed
Finally, Dr. Zeda Rosenberg, scientific director of the NIAID-funded HIV Prevention Trials Network at Family Health International, offered insight into the basic mechanics of HIV transmission in her presentation, "Approaches to Preventing HIV in Women."
Focusing on female-initiated prevention strategies, she said, there is a strong rationale for developing, for example, a topical microbicide that is both biodiffusable and bioadhesive able to reach the "mountains and valleys" within the vagina, and stay in place during sex. It's also important, she noted, that whatever preventive is developed not interrupt the various natural defense systems of the vagina.
Acknowledging that scientists still are not sure exactly where in the female genital tract HIV transmission occurs, she said it is important that researchers designing prevention methods for women consider the intricacies of the female anatomy. Somehow, Rosenberg explained, HIV manages to get past the natural defense mechanisms within the vagina.
Agreeing with Cargill, Rosenberg said to stem transmission in women effectively, developers must consider the circumstances of women's lives.
"Most women are infected by their primary partner," she explained, "and male condoms are less likely to be used during these encounters." In addition many women face a high prevalence of nonconsensual sex, and sex with nonmonogamous partners. Therefore, a stealthy prevention method needs to be developed so women can use it without informing their partners.
In response to a question about how to reach the seemingly unreachable women who are needed to test new therapies, Rosenberg gave advice that could summarize the seminar: "Don't do business as usual. You have to provide transportation. You have to provide childcare. We have recruiters on the streets at 2 in the morning. You don't wait for these women to come to you."
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