From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference newspaper - Wednesday 22 July - part 3
Note: non-commercial reproduction.
Archive-Number: 5759
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 22 Jul 92 16:40:44 GMT

(article continued from part 2)

Integrated
The clients in our programme can now answer questions for each 
other. HIV really has been integrated into daily conversation. We 
don't have AIDS awareness day, questions come up every day. At 
first they just couldn't believe we were talking about issues related 
to sex. Now people discreetly take condoms home."
When most people talk about health education they mean 
prevention programmes. However, with increasing numbers of 
people living with HIV for longer periods of time, health education 
has expanded to include helping seropositives manage their illness.
Chris LaCharite, director of educational programmes for clients 
attending treatment centres run by Curaflex Health Services in the 
US, says that because there is not yet a cure, HIV-positive people 
have to rely on a variety of health maintenence strategies. They first 
have to learn about what is available in the health care system and 
then learn to make decisions about what will work best for them.
LaCharite says the measure of success in evaluating health education 
is the extent to which people do as they are told.

'Paternalistic'
However, he believes that is paternalistic. "One of the best means of 
evaulation is to look at how satisfied the client is in relation to the 
clinical interventions. If you recommend zidovudine and clients 
decide they don't want to takeit because of what their own research 
tells them, that doesn't mean         my health education has 
failed."Swanson believes that education about health management 
can also have a positive effect on prevention. By providing a general 
environment of openness and support, seropositive people may be 
more effective in making changes. This is why Swanson believes 
that HIV counselling and testing programmes should not be viewed 
as educational in themselves, but must be supported by additional 
educational programmes as well as clinical and referral services.
She says: "Clients do learn things in counselling sessions but they 
largely see testing as a means to find out if they are positive or 
negative. They don't seem to view it as an educational experience. I 
often think clients are just too nervous to focus on the educational 
components of the counselling and testing session."
Nellie Mathu, who chairs the African Women Against AIDS Network 
in New York City, agrees that the whole system of HIV services 
must be designed and evaluated together. In particular, much more 
attention needs to be paid to the social and cultural context of 
education, both in design and evaluation.
Mathu says: "We need closer attention to the conflicts that arise 
between avoiding HIV in cultures where childbearing is important. 
We also need to look at the impact of support programmes. For 
example, programmes which assist children of HIV-positive women 
are very important, but we have also seen women weep when they 
test negative because their children cannot use the programmes."
The issue of partner notification has been extremely controversial 
in developed countries, especially when it comes to heterosexual 
couples. 
Many believe that wives and steady partners have a right to be told 
that their partner has tested positive. On the other hand, this 
information alone may not help the couple to make behaviour 
changes. Johnson says: "Partner notification is no alternative to 
education."
Even while researchers are deciding what works, there remain 
major areas where little or no health education has been 
implemented. According to LaCharite, the largest gap in services is 
to people in the lower socioeconomic strata. But more is required 
than simply setting up more educational programmes or creating 
more opportunities for drug treament.

Disadvantaged
He says: "When you're dealing with people who are economically 
disadvantaged, they are often educationally disadvantaged as well. 
You have to adjust educational strategies to help them gain skills in 
literacy or other educational areas as well as learning about 
HIV."Johnson believes the whole approach to prevention education 
needs to change."The thing that hasn't been considered enough is 
that we have until now focused most of our work on negative 
messages, sex is bad for you, you get STDs or pregnant. We need to 
look at positive images - you don't sell soap because it makes you 
clean, but because it smells nice or feels good. It's a social 
marketing idea. Safe sex needs a positive image, as part of an 
imaginative sex life."
*********************************************************
Men who have sex with men still matter - everywhere

Increasing emphasis on heterosexual transmission of HIV/AIDS can 
mean that homosexual transmission is at risk of being neglected in 
prevention programmes. This would have serious consequences for 
both developed and developing countries. 
We should acknowledge the success of interventions to prevent HIV 
transmission that have been initiated from within the gay 
communities in developed countries. As a result of these 
interventions, surveys have found widespread behaviour change and 
a reduction in the incidence of STDs and HIV. 
However, we must also recognize that these changes have not 
eliminated all risk of new infections or that the task has been 
accomplished once and for all. Consistent maintenance of modified 
behaviour requires long-term community support, including the 
shifting of community norms, for these changes to be sustained. 

Permanent risk elimination is not possible, because young men, the 
newly sexual, continually enter populations where HIV is prevalent. 
An increase in the incidence of STDs and HIV among some 
populations of young gay men has been attributed to the fact that 
many of these men have yet to be reached by prevention 
programmes. 

'Invisibility'
In addition, we now know that some men who have sex with men 
do not identify themselves as homosexual. The relative invisibility of 
men who have sex with men in much of the developing world tends 
to be increased by cultural factors and legal sanctions that drive 
homosexual behaviour under-ground. 
In consequence, many men who have sex with men also have sex 
with women, particularly in societies where marriage is nearly 
universal. This means that the occurrence of seropositive women 
and paediatric HIV infections, while it is the immediate 
consquence of male-to-female transmission, may ultimately be the 
result of bisexual behaviour among male partners. 
In developing countries, male-to-male transmission may be 
underestimated if this lack of congruence between sexual behaviour 
and self-identity is not taken into account. 
Alarming
For all these reasons, in countries where gay and bisexual men still 
account for the largest population of HIV-infected people, 
continued efforts are needed to prevent the acquisition and 
transmission of HIV within gay communities. Any reduction or 
withdrawal of services in these communities could have alarming 
consequences for the control of the epidemic. 
Innovative outreach programmes have been developed by gay 
communities in developed countries that start from the centre of 
the gay community and move to marginalized men who may be 
sexually, but not socially, engaged with gay-identified men. 

Fledgling gay organizations in many countries are capable of 
delivering similar outreach programmes that target a wider group 
of men who have sex with men, both those at the "centre" and 
those at the "margins". By targetting all men who have sex with 
men, we can reduce the incidence of HIV infection within the gay 
community and prevent the epidemic from diffusing to other 
populations.  

Meurig Horton 
High-risk Behaviour Unit, 
Office of Intervention Development and Support,
Global Programme on AIDS, World Health Organization,
Geneva, Switzerland 
*********************************************************
Perspectives:

TB - preventable but still spreading

Dr James Curran of the US Centers for Disease Control has said: 
"TB and HIV hang out together, and they're a bad influence on each 
other."  Throughout the world, tuberculosis has become a major 
threat to patients who are infected with HIV. Janis Kelly reports on 
TB control efforts in Africa and the US.
  
Carl Schieffelbein:
Decade of ground lost

The HIV-related rise in TB represents "a decade of ground lost" in 
the fight against this disease in the US, says Carl Schieffelbein, 
deputy director of the Centers for Disease Control's (CDC) 
tuberculosis elimination division.  
Between 1953 and 1984, the number of new cases every year 
declined from 84,000 to 22,000 in the US. 
Over the seven years that followed, cases increased by 18%, with an 
estimated 39,000 excess cases by 1991. Schieffelbein, who 
contributed to the new CDC action plan to combat multidrug-
resistant TB, attributes this reversal partly to increased emigration 
from areas of the world where TB is endemic and partly to a rise in 
active TB among people with HIV, due to their general vulnerability 
to infections. An uninfected person has only a one in 10 chance of 
contracting TB in their lifetime. By contrast, infected people have a 
nearly one in 10 chance each year.

Drug resistant
Drugs to treat TB are widely available in the US. But because many 
patients fail to complete the entire course of therapy, there has 
been a dramatic increase in cases of multi-drug resistant TB. The 
CDC recently reported that 14.9% of all TB cases tested during the 
first three months of 1991 had organisms resistant to at least one 
anti-TB drug, and 3.3% were resistant to both isoniazid and 
rifampin, the two most effective drugs available. This poses a 
particular risk for health care workers. At least nine have 
developed active, multi-drug resistant TB and five of those have 
died.  The new CDC plan aimed at this problem has two parts:  
detecting and treating active cases, and detecting and preventively 
treating people with latent infection who are at risk of developing 
active TB, including those with HIV. 

Little experience
Schieffelbein points out that these approaches are complicated by 
the fact that TB had become so uncommon in the US that many 
physicians have little experience treating it. Furthermore, since 
most new cases affect the poor and the US lacks national health 
coverage, getting these people into the system for diagnosis and 
treatment is difficult. Finally, even if the infected person can afford 
medical care and has a doctor knowledgeable enough to test for TB, 
immune suppression due to HIV can cause false-negative readings 
on the standard skin test.
Importantly, data from African researchers (see related stories, this 
page) show that patients with HIV and TB are probably less likely to 
spread TB than those without HIV. Nonetheless, concern over 
multi-drug resistant TB developing in noncompliant or inadequately 
treated patients led to the CDC's most controversial recent 
proposal:  directly-observed therapy (DOT), including court-
ordered and involuntary detention during the six to nine months 
required for treatment.

Muzuwa Banda:
We need drugs and transport

Money to buy drugs to treat TB and motorcycles to help health 
workers reach TB-infected patients are both needed before much 
of a dent can be made in the double epidemic of TB and HIV in 
Zambia, says Dr Muzuwa Banda. Banda, a physician who has 
practised in several hospitals in Zambia and who is involved in 
developing AIDS control programmes, points out that the increased 
incidence of active TB in adults aged 20 to 50 is a sign that HIV is 
an increasing and already widespread problem. 

Deadly 
Previously, active TB was more commonly seen in children and the 
elderly. Banda has found that 60% to 80% of his patients with 
active TB are HIV seropositive. "In endemic areas such as ours, TB 
therapy must be provided free and it must be easily available before 
the disease can be brought under control," Banda says. This point 
assumes more importance, now that TB has been identified as the 
most deadly AIDS-associated infection in Africa (see related story, 
this page).

Expensive
The most commonly available drug therapy in Zambia is the 
streptomycin-based regimen, which requires injections. The oral 
rifampin/isoniazide-based regimen would be better, says Banda, but 
is much more expensive. 
Motorbikes would also help. Banda would like better transport for 
TB workers to be able to move around the districts, visiting 
patients to assure compliance; monitor clinical status; and to watch 
for other HIV-related problems.
Banda would also like to see more training for health workers in 
how to diagnose coexistent TB and HIV. TB in HIV-infected 
patients often presents in an unusual way because it tends to appear 
in places other than the lungs. This complicates diagnosis but has a 
bright side:  it reduces the risk of TB transmission to others. "In 
HIV-positive patients, the risk is probably lower because TB tends 
to appear in closed organs rather than causing cavities in the lungs 
and being spread into the atmosphere by coughing," Banda says. 
"There is probably no higher risk of health workers getting TB from 
an HIV-infected patient than from TB patients who do not have 
HIV. The risk is in the sheer numbers of any type of patient with 
TB."

(article continued in part 4)

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