From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference newspaper - Wednesday 22 July - part 2
Note: non-commercial reproduction.
Archive-Number: 5758
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 22 Jul 92 16:40:17 GMT

News in brief

Seminal fluid

There is a risk that the pre-ejaculatory fluid of HIV-positive men 
can transmit the virus, Gerard Ilaria from New York Hospital said in 
a Recent Report session on Monday evening. 
Ilaria was able to detect DNA derived from the virus with the 
polymerase chain reaction technique in the pre-ejaculatory fluid of 
six out of 14 seropositives. 
He could find no statistical correlation with the T4 count of the 
men tested or with an anti-retroviral treatment. 
The quantity of pre-ejaculatory fluid is low, less than 0.5 ml, but it 
may pose a risk in oral and vaginal sex.
Ilaria's results have been confirmed by Jeffrey Pudney, from 
Harvard Medical School in Cambridge, Massachusetts, who has a 
poster on the same subject. Pudney looked at T4 cells in pre-
ejaculatory fluid. "It is not a potential vehicle for transmitting the 
disease,"Pudney says, "it is a vehicle."

Antiviral resistance 

Strains of HIV resistant to zidovudine are readily isolated from 
patients who have had long-term therapy. 
Such strains are also thought to lead to the worsening of the 
patient's condition, said Brendan Larder, of Wellcome Research 
Laboratories in Beckenham, UK. But, as yet, there is no definite 
proof. 
Resistance has been tightly linked to clinical consequences for a 
new class of drugs, the non-nucleoside reverse transcriptase 
inhibitors such as nevirapine, said Dr Clyde Crumpacker, of Beth 
Israel Hospital, Boston, at yesterday's Round Table on the Molecular 
Basis of Drug Resistance. 
Douglas Richman, of the University of California, San Diego, said in 
vitro studies run in parallel with clinical trials showed that a 
resistant mutant appeared at the same time that patients' CD4 cells 
dropped and p24 antigen rose.

Astra activism 

Because of a threatened disruption by ACT-UP, Astra cancelled the 
reception planned to follow its symposium on virus treatment last 
night and donated the food to the Amsterdam Salvation Army. 
G'Dali Braverman, a member of ACT-UP Golden Gate (California) 
said: "Giving away food is not the solution to saving people's sight."
*********************************************************
Two drugs may be better than one
By William Check 

Researchers are beginning to reach a consensus about how to 
combine antiviral drugs for the treatment of HIV infection.
Dr Robert Yarchoan, of the National Cancer Institute (NCI) in 
Bethesda, Maryland, said: "We're at the point where there's a lot of 
enthusiasm and some consensus about how to put drugs together. 
Now we need large controlled studies, rigorously comparing 
combinations containing either      ddI (didanosine), or ddC (dide-
oxycytidine, zalcitabine) plus zidovudine versus monotherapy in 
early and advanced disease. We really can't predict from first 
principles which are going to work." A likely combination is 
zidovudine plus ddI.
Several presentations at an Oral Abstract session on combination 
antiretroviral therapy on Monday reported results of trials with 
zidovudine plus ddI, as well as other combinations. Yarchoan called 
protease inhibitors "the optimal choice" for combination with 
zidovudine, since these drugs act at different sites and should be 
synergistic. However, no protease inhibitor has yet finished Phase I 
trials.
After Monday's session, Dr Nathan Clumeck, of the University of 
Louvain, Belgium, said: "There are fewer and fewer arguments 
against combination therapy and more and more information that it 
could be useful, especially in maintaining the CD4 level, which is 
still our goal."
Combination therapy will be necessary because so far all 
antiretroviral drugs have drawbacks such as toxicity and 
development of viral resistance. Samuel Broder, director of the 
NCI, said at Monday's State-of-the-Art lecture on drug therapy: "My 
feeling is that these problems will apply to all agents that we will 
see in the near future."
Synergistic effects
Combination therapy may also be more effective than monotherapy 
because the two drugs may have synergistic effects. Zidovudine 
(formerly AZT) decreases the amount of virus in the blood by a 
factor of 10. Speaking at a satellite symposium on Sunday, 
sponsored by The Wellcome Foundation,      Dr Robert Schooley, of 
the University of Colorado Health Sciences Center, put that effect 
into perspective. "If I were standing here talking to you about an 
antibiotic that decreased the amount of E. coli in the blood by 10%, 
you would be pelting me with tomatoes," he said. Although several 
studies have been done adding either ddI or ddC to zidovudine, 
Schooley said, there is no unequivocal evidence yet of clinical 
benefit from these two combinations. His data illustrated the kind 
of benefits seen to date. Seropositive people with less than 300 
CD4 cells were treated with zidovudine with or without ddC. 
Patients treated with zidovudine alone had an average increase of 
50 CD4 cells, but CD4 levels returned to baseline within six 
months. With zidovudine plus ddC, there was an increase of about 
100 CD4 cells, and the values remained above baseline at six 
months.
Speaking at Monday's Oral Abstract session, Yarchoan and his 
colleagues compared simultaneous combination therapy with 
zidovudine and ddI to alternating treatment with zidovudine and 
ddI. Patients had AIDS or symptomatic HIV disease, with 20 to 350 
CD4 cells. In the simultaneous treatment arm, there was a greater 
and more sustained CD4 increase. "We were surprised by the 
magnitude of this difference," Yarchoan said.
Dr Margaret Ragni, of the University of Pittsburgh, presented one of 
three studies with zidovudine plus ddI. In 106 asymptomatic 
patients with 200 to 500 CD4 cells, the cell count rose by 12% to 
24% over the 24 weeks of treatment and remained elevated for one 
year. But CD4 cells rose the same amount in all three combination 
arms and in the control arm of ddI alone. No control arm was done 
with zidovudine alone. 
In a Recent Report session, Dr Ann Collier, of Harborview Medical 
Center, Seattle, showed higher and more sustained increases in 
CD4 cells with combined treatment with zidovudine and ddI than 
with zidovudine alone. There was no difference in patients' 
responses to the five combination doses. Subjects had less than 400 
CD4 cells, and many had AIDS or AIDS-related complex.
There were three other reports on drug combinations at the Oral 
Abstract Session. 
Dr Clifford Lane, of the National Institute of Allergy and Infectious 
Diseases, tested zidovudine plus interferon-alpha versus each alone. 
At one year, there was a slight increase in CD4 cells in all three 
groups, but no difference among groups. 
Early data 
Dr Sarah Cheeseman, of the University of Massachusetts, 
Worcester, reported very early data on zidovudine plus the non-
nucleoside reverse transcriptase inhibitor, nevirapine. There were 
beneficial changes in both p24 plasma antigen and CD4 cell counts, 
but they rapidly returned to baseline. But the dose was limited 
when patients developed rashes, leading Clumeck to ask, "Is there 
a future for this drug?"
On behalf of the European-Australian Acyclovir Study Group, Mike 
Youle officially presented the results of a study with zidovudine plus 
acyclovir that was widely reported in the popular press earlier this 
year. The mortality at one year was decreased in the combination 
drug arm, even though there was no decrease in cytomegalovirus 
infections - the rationale for using acyclovir. 
Youle said it was difficult to recommend this regime without being 
able to explain the mechanism that accounted for the fall in 
mortality. A larger trial of this regimen is now under way.
*********************************************************
Street kids need the power to help themselves
By Cindy Patton

Teaching street kids how to survive in their environment is the 
first step in helping to prevent HIV transmission in this group, said 
Edith Springer in yesterday's session on working with street youth.
Springer runs a project for gay and bisexual homeless youths, many 
of whom engage in prostitution in Times Square, New York City. 
The two-year-old project, which pays 10 street youths to educate 
their peers, reaches more than 70 other youths per week.
Springer believes it is more effective to promote self-esteem  than 
to advocate abstinence and leaving sex work. "The first thing I did 
was to teach them to be really good prostitutes, to be safe 
prostitutes and safe drug users. A lot of them were giving blow jobs 
and then asking for the money. I told them to get the money first. 
Now they don't get beaten up and pushed out of the car." 
Springer is critical of the 'recovery' model common in the US, 
which emphasizes abstinence. "I worked for many years using the 
abstinence model and I had almost no success," she said. "But in 
two years of emphasizing empowerment and self-esteem and 
addressing their life issues, several youths became abstinent and 
many more decided on their own that they wanted to get off drugs."
Dr Irene Bruinsma Adams, who runs a clinic for street kids in Belo 
Horizonte, the third largest city in Brazil, with 3.5 million 
inhabitants, said that at first she did not believe that it was possible 
to work with street kids who were still living on the streets.
In 1989, Adams opened a clinic for the 600-700 "true" street 
children living in the centre of the city. These children have no 
shelter but "live, love and eat" on the streets. The children live 
alone or in gangs and rely on scavenging, odd jobs, petty theft and 
prostitution to survive. 
One in four of her patients are girls, some of whom have had three 
children in the three years the clinic has been open. 
Adams currently sees six seropositive street children out of the 620 
children who have attended the clinic since it opened. Few have a 
test until they have symptoms, so she believes there are many 
more.
The clinic provides health education for the children while treating 
their immediate medical needs, she said. When they refer children 
to other health care providers, Adams escorts them the first time. 
"I have a photo album, and when I see the health provider I show 
them pictures and I say, 'here is the reality of the child you are 
about to treat'." 
*********************************************************
Does health education work?

After a decade of insisting that "education is the only weapon we 
have," policy makers, funders, educators, and communities who 
have themselves been the targets of education want to know the 
answer to this question. Cindy Patton reports.

Does health education work?
The answer might not be so easy to discover. As Dr Nancy Swanson, 
consultant and ethnographic coordinator of a major US study of the 
impact of HIV counselling and testing on methadone clients puts it:
"It depends on how you define 'works'."
Much evaluation of health education on HIV has defined success in 
terms of decreased risky behaviour, creating a bias toward 
implementing programmes that focus on the individual, says 
Swanson. 
Variations
However, before individuals undertake their own changes, changed 
attitudes and social support for behaviour change may need to be in 
place in their communities. These subtle variations are difficult to 
identify, much less evaluate. According to Swanson, pro-grammes 
aimed at the individual sometimes have community-wide 
consequences, but these larger changes are missed if the evaluation 
looks only at changes in individual behaviour. For example, the 
preliminary but necessary change in the attitudes of drug users 
about the acceptibility of bleaching syringes may not immediately be 
reflected in the behaviour of specific individuals.
Swanson says: "Some health education programmes might enable 
clients to make general  changes in their lifestyle and relationship 
that enable specific changes later on. Changes at the community 
level, like changes in the stigma attached to HIV, and an increase 
in the openness of discussion, help make new behaviours become 
more normalized within their reference group. For example, when 
condom use becomes accepted you will be more able to use them, 
you won't feel as though people think there is something wrong 
with you or that you don't trust them."

Multiple approach
That's why Dr Anne Johnson, senior lecturer in epidemiology at 
London's University College and Middlesex School of Medicine, 
advocates education at many levels, including large-scale media 
campaigns, education in schools, programmes directed at specific 
populations in formal settings like clinics, as well as projects in 
which people work with others like themselves in their own 
communities. But this multiple approach only makes evaluation 
more difficult.
Johnson says: "Huge amounts of money have gone into health 
education - both big media campaigns, community projects and 
counselling. There is so much going out, it's hard to separate out 
the interventions. Can you really put your hand on your heart and 
say your little outreach project resulted in the behaviour change?"
Johnson identifies two new trends designed to grapple with the 
problem of how to evaluate overlapping interventions. Tracking 
simple indicators - for example, numbers of teenage pregnancies or 
incidence of STDs - shows whether there have been general 
changes in the right direction. But such measures do not show 
exactly which people have made changes or why.
So evaluators are increasingly using qualitative techniques like 
interviews, observations, and participation in groups with high-risk 
behaviour in order to understand better what changes mean to 
individuals and how they have been integrated into communities. 
Newer studies mix quantitative and qualitative techniques in order 
to "measure fashion," as Johnson puts it. She illustrates the value of 
this approach with an anecdote from an interview with a young man 
who described oral sex as an alternative to vaginal intercourse.
"Previously, we had viewed oral sex as a practice of the more 
sophisticated. We wouldn't have realized that oral sex was emerging 
as a conscious safe sex alternative if we hadn't talked to some young 
people. So, exploratory researches are really important in terms of 
helping us find out what questions we should be asking."
Qualitative evaluations that look for general changes are also popular 
among educators evaluating single programmes.
Mary Stuart Petty, manager and developer of Spreading the Word, a 
Halifax, Nova Scotia-based programme for people with psychiatric 
illnesses, has begun to evaluate the programme's progress. She 
looked to see what had changed from the time that the project first 
assessed its needs. Both staff and clients lacked some of the basic 
information about HIV but, perhaps more significantly, the staff did 
not know how to introduce the topic of sexuality or how to make 
connections with existing community resources. Petty asks clients 
and staff to fill in standard knowledge questionnaires. She also 
monitors referrals of her clients to self-help groups and medical 
services. But the criterion for success is, well, fashion.
Petty says: "I think about success in terms of open discussion. 
People are asking questions and offering information. 

(article continued in part 3)

-- 
Matthew Lewis, University of Amsterdam		Grote Bickersstraat 72
+31-20-52 51 220				1013 KS  Amsterdam
Internet: matthew@ooc.uva.nl			The Netherlands
Newsgroups: sci.med.aids