From: Billi Goldberg <bigoldberg@igc.apc.org>
Subject: AIDS Conference Newsletter 7/21/92
Note: non-commercial reproduction.
Archive-Number: 5755
Organization: UCLA, Computer Science Department
Date: Wed, 22 Jul 92 07:32:30 PDT

The following includes first three parts of the HIVNET AIDS CONFERENCE
NEWSPAPER dated Tuesday, July 21, 1992.

Compliment of the International AIDS/ARC FidoNet Conference
************************************************************************
************************************************************************
Msg#:27232 *Int'l AIDS/ARC* 
07/21/92 22:34:00 
From: MATTHEW LEWIS 
  To: ALL 
Subj: CONFERENCE NEWSPAPER - TEUSDAY 21 JULY  - P 
Hello all, 

Here is the Conference Newspaper, Tuesday 21 July.  This paper  
comes to you courtesy of HIVNET, an organization based in the  
Netherlands which has set up a network of BBS systems for the  
spreading of information about HIV and AIDS.  It is made possible  
by the kind permission of the Aids Congress Foundation. 

********************************************************* 
Variety: the key to HIV control   
by Janis Kelly 

The HIV/AIDS epidemic is changing direction, the virus is  
changing its coat and human social systems are not changing fast  
enough, according to speakers in yesterday's plenary session on  
Longitudinal Trends in the Epidemic.   
Dr Michael Merson, director of the WHO's Global Programme on  
AIDS, said: "Yesterday, the HIV pandemic was concentrated in  
cities and towns. Today, the virus is following roads and navigable  
rivers deeper and deeper into the countryside." He added that HIV  
incidence in Asia is skyrocketing and that, without adequate  
prevention programmes, the number of new infections in Asia will  
overtake that in Africa some time during this decade.   

Sharing 
He called for human rights, replication of effective prevention  
programmes and greater sharing of resources between developed  
and developing nations. He said: "Now that the developing  
countries have mustered their courage and pledged their  
commitment to fighting AIDS, it would be a cruel irony if the world  
did not match this effort with the funding needed." 
A great deal of effort has already been invested in studying the  
variability of HIV. Dr Gerald Myers, of Los Alamos National  
Laboratories in the US, described a wider spectrum of HIV genetic  
diversity than had been originally observed. There are at least five  
major subtype lineages of HIV-1, and each subtype changes about  
1% of its genes each year.   

'Swarm' 
Myers said that an HIV-infected individual soon becomes host to "a  
swarm of distinguishable variants"differing from each other by about  
5%. He raised the possibility that infection by one subtype of HIV  
may actually prevent infection by another subtype. No one has ever  
been found who is infected with more than one subtype (not to be  
confused with variants of subtypes). It might be possible to harness  
this apparent inhibition, protecting people against lethal subtypes  
by inoculation with a less deadly one. Myers said this theory might  
lead to a prophylactic vaccine but doubted that the world was "quite  
ready"to risk using an infectious agent, even a defective virus, to  
protect against AIDS. 
At the moment, the only strategy for protection is change in  
behaviour. Questioning how we could achieve this, Dr Anke  
Ehrhardt of Columbia University, New York, said we should try to  
learn as much about human sexual variety as we know about viral  
variety. Ehrhardt said that public health and moralistic attitudes  
continue to come into conflict: "The moralising position may range  
from labelling sexual behaviour outside of heterosexual marriage as  
sinful, in which case disease prevention becomes secondary to  
moral principles, to the extreme position that if the sinner does  
not change his or her sexual behaviour, he or she may be doomed  
and deserve to die." 
There is growing evidence that properly designed AIDS prevention  
programmes do cause change in people's sexual behaviour, said       
Dr V. Chandra Mouli of the         All India Institute of Medical  
Sciences. He cited a WHO study of 15 projects in 13 countries  
which found that safer sex practices are being adopted by ever- 
growing numbers of military recruits in Rwanda, truck drivers in  
Tanzania, sex workers in Zimbabwe and other groups in risky  
situations. 

Burden 
However, in the developing world, the burden of caring for people  
with HIV and AIDS still falls largely on the extended family network  
and Mouli says that "the strands of this safety net have become  
increasingly frayed". Care of children orphaned by AIDS has passed  
to a generation of elderly grandparents.  
Mouli says: "Extended family networks and social support systems  
are beginning to falter because they are overwhelmed by the  
endless demands made on them"and warns that entire  
communities face "destitution and even disintegration"without  
outside help.  

********************************************************** 
Vaccine toxicity is low 
by William Check 

A candidate vaccine containing HIV envelope protein has produced  
promising results in a pilot study on humans. Delegates at the  
session on prophylactic HIV vaccines heard that the candidate  
vaccine, which contains a recombinant version of gp120 from the  
IIIB strain of HIV, could stimulate antibody responses and cell- 
mediated immunity.  
Tests in chimpanzees had already shown that the candidate vaccine  
could protect the animals against viral challenge. Two years after  
the challenge, there was still no sign of infection. 
For the tests in humans, Dr Mary Lou Clements of Johns Hopkins  
University, along with other researchers, immunised 25 healthy  
HIV-negative volunteers at low risk of HIV infection at 0, 1 and 8  
months, with either 100 or 300 mcg of the vaccine in alum or with  
alum placebo. The trial was double-blind. 
Clements said the candidate vaccine was tolerated well. All  
volunteers receiving the active preparation had specific antibody  
responses. The higher dose was more potent. At two weeks after  
the third immunization, the anti-rgp120 titer was 4.0 for the  
higher dose and 3.4 for the lower dose.  
Blocking antibody against the V3 hypervariable loop of the peptide  
and blocking antibody against CD4 was present in 90% and 100% of  
those receiving the 300 mcg dose, respectively. Nine of 10 had  
neutralising antibody, with a mean titer of 1:58, "the highest we've  
seen with a IIIB envelope vaccine,"Clements says.  
A lymphoproliferative response to rgp120 was present in nine of 10  
subjects receiving the higher dose. Two people tested more than  
six months after the second booster retained this response. 
Some researchers have suggested that cytotoxicity may be more  
important than neutralising antibody for protection against HIV. 
"Cytotoxic cells may restrict virus replication after infection, but  
they don't correlate with prevention of infection,"Clements says.  

********************************************************** 
Liz Taylor: Scientists unite! 
By Simon Rozendaal 

Amfar, the American Foundation for AIDS Research, is to give  
almost US$300,000 for AIDS work in Argentina. Elizabeth Taylor,  
the founding chairman of Amfar, announced at a press conference  
yesterday that the money would be shared between six prevention  
projects aimed at the gay community, drug users, young women and  
HIV-positive people and their families. 
Taylor reinforced her commitment to the battle against AIDS. She  
said: "I am tired and I am grieving.  

Tired of having to convince the world out there, over and over  
again, that AIDS is a universal threat to all mankind".  
She appealed to scientists: "Here and now we are all fellow  
travellers on the road to defeat AIDS. From the lab bench to the  
bedside, from the icy north to the deep south, we are all part of the  
world community that does want to stop AIDS now." 
Miss Taylor urged women to take the risk of HIV seriously. "It can  
be contracted vaginally, it does not have to be anal sex", she said. 

********************************************************** 

Fight to get condoms and syringes into prisons 
By Simon Rozendaal 

Many prisons carry out mandatory HIV-testing and in some there is  
systematic segregation of prisoners infected with HIV, delegates at  
a session on Sex and Drugs in Prisons heard yesterday. In most  
prisons there is no distribution of condoms and there are neither  
clean syringes nor bleach for cleaning them, making it difficult or  
impossible for prisoners in most countries who need to protect  
themselves against HIV and AIDS to do so.  
Ted Hammett, from the consulting company Abt Associates in  
Cambridge, Massachusetts, said most prisons therefore do not  
comply with the WHO's recommendations published in 1987. He  
said mandatory HIV-testing took place in 17 out of 51 American  
prisons and 5 out of 27 European prisons. The same survey showed  
that five out of seven Australian prisons segregate HIV-positive  
prisoners.  
Condom distribution is a particular problem, delegates heard. Only  
two out of 51 US prisons distributed condoms. In Europe, the  
situation is slightly better. Out of 27 European prisons, 16  
complied with the WHO's recommendations on condoms. Several  
speakers at the session said that prison authorities and politicians  
in many countries are reluctant to hand out condoms. Sex among  
inmates is officially forbidden. 
Oscar Simooya from the University of Zimbabwe presented a study  
in five Zambian prisons with a seroprevalence rate of 16%. There  
was no policy to hand out condoms, Simooya said. "The prisoners  
do not want it themselves. It is a difficult problem for us." 
Mercedes Diez from the Spanish penitentiary authorities told  
delegates that it is possible to distribute condoms in prisons  
without creating significant problems. In Spain, which has a high  
rate of seroprevalence in prisons (about 55% in Madrid), condoms  
are handed out in every prison. The inmates receive the condoms  
along with toiletry items at entry. "They do not have to ask for  
them", Diez said. She could not make any estimate of the extent to  
which prisoners use condoms, however. 
HIV/AIDS is causing huge problems in prisons. Especially in  
countries like Spain and Italy, where a large proportion of drug  
users are infected, the level of seroprevalence in prisons is high. All  
over the world, prevalence in prison is higher than outside. 
In the USA alone, almost 7,000 inmates have AIDS. In the New  
York prisons, an epidemic of TB related to HIV is raging. Stephen  
Machon, a member of ACT UP, said that in the last quarter of 1991,  
13 prisoners died in New York jails because of TB. The mortality  
rate from AIDS in prisons is more than ten times higher than the  
New York average, Machon said. 
The session was the first at an international AIDS conference to  
address the issue of sex and drugs in prison. Speakers as well as  
audience applauded the initiative. Hammett said: "It is an issue that  
concerns the whole of society, because most prisoners return to  
society after completing their sentences." 

Behind bars: many prisons fail to supply inmates with condoms or  
syringes to prevent the spread of HIV 

Photo: R. Podorni/TASS 

********************************************************** 
Sex workers face harsh penalties 
by Cindy Patton 

Sex workers who are illegal aliens in Thailand face deportation and  
sometimes death, according to a prostitute's pressure group there.  
Chantaiwipa Apisukh, of EMPOWER (Education Means Protection of  
Women Employed in Recreation), an organisation based in  
Bangkok, Thailand, said that earlier this year about 20 women who  
were deported to Burma and tested HIV positive on their return  
were killed by lethal injection. 

Concern 
Apisukh, who met with Asian campaigners at Saturday's satellite  
meeting of some 250 sex workers and community organizers,  said  
sex workers in Thailand, where the sex industry is focussed on sex  
tourism, are now highly organised to campaign for their rights. But  
she is concerned that sex workers will not be properly informed  
about the benefits and harms of participating in the HIV vaccine  
trials planned for Thailand. 
"These women are very poor and marginal. If they join the trial it  
isn't really of benefit to themselves, but to the next generation.  
Some may die sooner as a result of the trials.  We want  
compensation for them and a guarantee that they will receive  
treatment." 
Marie-Helene Mottin-Sylla, who directs a project that supports sex  
workers in Dakkar, Senegal, said that the organizing work among  
Western prostitutes has been important, but may not be easily  
applied in Africa: "It is important to learn strategies. We need a  
global solution, but we also need to develop local ways." 

Traditional life 
Because sex work in Africa is not related to tourism or large  
businesses, prevention strategies used in countries like Thailand  
may not work as well in Africa, said Mottin-Sylla. "Except for a very  
few resorts, in the cities, it is largely local prostitution. 
Traditional  
life is hard on women, both in terms of economic conditions and in  
terms of patriarchal relations. More and more women want to leave  
the smaller towns and countryside to go to the big world of modern  
life, where they have no other economic or social means of  
survival." 
Swaminathan Sundararaman, of the AIDS Research Foundation of  
India (ARFI) in Madras, who has conducted studies to determine  
STD transmission patterns between clients and sex workers from a  
variety of different settings, said that in India, sex work is 
stratified  
by class. "Street workers see migrant labourers who either have  
wives at home, or are single." 
But in the mid-1980s, the researchers saw a new pattern of sex  
work in which middle-class women sell sex from their homes five  
or six times a month, said Sundararman. "With the failing economy,  
middle class families can't pay their bills. These are older women  
whose clients are men of the same class. It's very discreet, like a  
relative coming to visit." 
Diana Alan, consultant to the National Transsexual and HIV Needs  
Analysis funded by the Australian government said she has  
identified transexuals as a subset of sex workers with specific  
needs. 

'Worthless' 
She said that young people who do not conform to gender  
expectations of their cultures are likely to be thrown out of their  
homes. They become "educationally disad-vantaged and believe they  
are unwanted, unemployable and worthless. They leave home and  
school, enter into sex work early and stay there,"Alan said. In her  
study, 40% of transexuals had engaged in drug injection and 80%  
had at some time been involved in sex work. Alan notes that  
transexuals are not covered by any discrimination laws or included  
in existing prevention strategies: they are considered neither  
women nor homosexuals. "Transexuals in the Third World are  
treated even worse than women,"Alan said. 

Magic bullet 
Priscilla Alexander, who directs a project on prostitutes at WHO's  
Global Programme on AIDS, applauded the inclusion at the  
conference of more front-line organizers from sex work projects. 
"The main problem is that people are still  looking for a magic  
bullet,"said Alexander. "The most essential part of prevention is  
community identity. People have to believe that their own lives are  
valuable. The best way to do this is to organize people and work  
with them to help them realize that they are valuable and  
worthwhile." 

(end of part 1 of 4) 
--- GEcho 1.00/beta 
 * Origin:  (2:280/413) 
************************************************************************ 
************************************************************************
Msg#:27233 *Int'l AIDS/ARC* 
07/21/92 22:35:00 
From: MATTHEW LEWIS 
  To: ALL 
Subj: CONFERENCE NEWSPAPER - TUESDAY 21 JULY - PA 
CONFERENCE NEWSPAPER - Tuesday, 21 July - part 2 of 4 

********************************************************** 
Growth factors help antiviral therapy 
by Wim Zeijlemaker 

Recombinant haemopoietic growth factors can help in the  
treatment of AIDS, the latest studies show.  
The results obtained so far in AIDS patients being treated with AZT  
and/or ganciclovir are promising.  
These antiviral drugs frequently cause anaemia, which means  
therapy must be interrupted until the patient's blood count  
recovers. But treatment with the growth factors appears to reduce  
the need to interrupt therapy, as well as improving the patients'  
quality of life. Recombinant human haemopoietic growth factors  
have only recently become available for therapeutic use in humans.  
They include recombinant granulocyte-macrophage colony- 
stimulating factor, recombinant granulocyte colony stimulating  
factor and recombinant erythropoietin (rGM-CSF, rG-CSF and  
rEPO, respectively). 

Skeletal pain 
Data presented in yesterday's session on haemopoietic growth  
factors dealt with the use of these recombinant factors to alleviate  
neutropenias and anaemias during treatment of HIV patients.  
Scientists from the US and Sweden studied 51, 6 and 17 patients,  
respectively, who were taking ganciclovir or zidovudine. The  
patients received doses of 5 to 10 ug/kg/day of GM-CSF and G-CSF  
for a period of up to seven months. The growth factors increased  
the counts of neutrophil leukocytes sufficiently to avoid the need to  
stop therapy temporarily. The only adverse effect was skeletal pain  
in a minority of patients.  
John Phair from North West University Medical in Chicago  
presented data on the effect of rerythropoietin in 1,943 AIDS  
patients during treatment with AZT. Of them, 40 % required at  
least one blood transfusion during the six weeks before they  
entered the study. After 12 and 24 weeks of treatment with r-EPO,  
this percentage dropped to 22 and 18%, respectively.   

********************************************************** 
The rise of the therapeutic vaccine 

Is a vaccine to delay or prevent the onset of AIDS in HIV-infected  
people waiting to make its debut? Or is it just wishful thinking?  
Sharon Kingman reports. 

Ever since it was first postulated that AIDS develops when the  
immune response against HIV proves inadequate, researchers and  
HIV-positive people have hoped that it may one day be possible to  
make a vaccine that would manipulate the immune system, delaying  
or preventing the onset of AIDS. 
Studies being presented at this conference provide some of the  
first indications that such a vaccine - a "therapeutic"vaccine - may  
be feasible. With the exception of the rabies vaccine, all vaccines to  
date have been given to prevent infection. But the results from the  
latest tests on vaccines for HIV show that they can induce new  
immune responses in people already infected with HIV. 
No one yet knows what such responses mean for infected people. It  
will be several frustrating years before researchers will be able to  
find out whether therapeutic vaccines can increase the life-span of  
infected people and allow them to remain healthier for longer.  

Rabies vaccine 
If such a vaccine can be shown to work in this way, it will be a first  
in immunology. Gordon Ada, emeritus professor in the division of  
cell biology at the John Curtin School of Medical Research in  
Canberra, Australia, points out that the only other vaccine that is  
given to people who are already infected is the rabies vaccine.  
"People know they have been bitten by a rabid dog and therefore  
when they may have been infected. It may take one or two weeks  
before the virus reaches the nerve endings and if you can vaccinate  
before that, you can often effect a cure." 
Encouraging signs 
But most people do not know exactly when they became infected  
with HIV. "If you knew when someone was infected and immunised  
them right away, you might achieve something before the virus got  
around the body and into lots of different types of cells." 
But once infection has taken place, it is too late for a traditional  
vaccine. "It's a case of can we give a vaccine that will mitigate or  
delay the course of the disease? It is too early to say how successful  
that is going to be, but there are some encouraging signs,"Ada says. 
The encouraging signs are coming from groups such as those led by  
Robert Redfield of the Walter Reed Army Institute of Research in  
Rockville, Maryland, and Fred Valentine of New York University  
Medical School, who are reporting this week that candidate  
vaccines made of recombinant gp160, the envelope protein of HIV,  
can stimulate the immune systems of people infected with HIV who  
have CD4 counts of 400 or higher.  
Redfield's group has been using the polymerase chain reaction test  
to monitor viral load in HIV-infected volunteers given the vaccine,  
looking at both total amount of genomic viral RNA (which reflects  
the amount of free virus) and the ratio of viral-associated messenger  
RNA to viral-derived DNA in infected cells. The higher this ratio,  
the more active the infection.  
The results, due to be announced today, show a decrease in viral  
load, a lower ratio of RNA to DNA and an increase in neutralising  
antibodies produced by cells of recipients of the vaccine. One of  
Redfield's studies has also shown that the rate of decline of CD4  
cells slowed in vaccinated subjects.  
Valentine says the hypothetical rationale for giving a vaccine to  
infected people is that "If one were able to induce a new immune  
response in an infected individual, that infection had not already  
provoked, then this might be of benefit."But, he warns, "we have no  
evidence for that". 
The trial by Valentine's group was placebo-controlled because, he  
says, "We wanted to see if the immune changes were related to  
receiving HIV as opposed to the stimulation caused by just any  
antigen. So subjects had to be antibody-positive for both HIV and  
hepatitis B." 
Normally, when a person's lymphocytes are put in contact with an  
antigen they have encountered before, they will respond by dividing  
or proliferating - the "lymphocyte proliferative response". Those  
who took part in Valentine's trial had normal lymphocyte  
proliferative responses to common microbes. But their responses  
to HIV antigens were negligible. 
However, after immunisation with rgp160 - but not after  
immunisation with hepatitis B vaccine - these people had a good  
lymphocyte proliferative response to HIV antigens. Valentine's  
group reports that their lymphocytes also made interleukin-2 when  
stimulated with rgp120 in the laboratory and, when shown cells  
with gp160 displayed on their surfaces, the lymphocytes showed  
increased cytotoxic ability. 
The fact that these changes occurred only after the gp160, but not  
after the hepatitis B vaccine, shows, Valentine says, that they were  
indeed the specific consequence of the vaccine, and not the result  
of nonspecific perturbations of the immune system, which could be  
caused by any antigen. 
The next step for Valentine's team will be to find out how ill  
someone can be with HIV infection and still respond to the vaccine.  
Trials will begin in the autumn in people with lower and lower CD4  
counts, Valentine says. After that will come a very large trial to find  
out if the vaccine can influence the clinical outcome: does it delay  
the onset of AIDS? Will vaccinated patients live longer? 

Pressure 
Some scientists believe that there is a danger that, if such vaccines  
are shown to halt the decline of CD4 cells in HIV-infected people -  
a so-called "surrogate"or "laboratory endpoint"- there will be  
enormous pressure to make such preparations available without  
waiting for the results of large trials such as that planned by  
Valentine. This would measure "clinical endpoints", in other  
words, the effect on the patients' state of health.  
Geoffrey Schild, head of the British Medical Research Council's  
AIDS Directed Programme in London, says: "There is a danger of  
people coming to hasty conclusions. Let's not confuse surrogate  
markers of benefit like virus load with people surviving longer with  
good quality of life. We need well-controlled long-term studies with  
good clinical endpoints." 
Phillip Berman, of Genentech, the Californian biotechnology  
company which is also testing therapeutic vaccines, sums up the  
dilemma: "If you go for clinical endpoints you will have to wait for  
years for the results, particularly if the trial subjects get the kind 
of  
health care that you get in the US. If the therapeutic vaccine works  
but you have to wait for the results, there's going to be a lot of  
people who could have been helped by such preparations who will  
not get them. But if you go for surrogate endpoints, you take the  
risk of potentially approving something that may not be effective." 
One reason why the emphasis on therapeutic vaccines is growing is  
that they are much easier to test. There is no shortage of volunteers  
to take part in efficacy trials. By contrast, efficacy trials for 
vaccines  
designed to prevent infection are fraught with practical and ethical  
problems. 
Berman believes that much work still needs to be done on  
characterising suitable populations to test prophylactic vaccines  
before trials can begin, as well as on many ethical problems.  
Participants must be counselled thoroughly on ways to change their  
behaviour to avoid the risk of HIV infection and discouraged from  
reverting to high-risk behaviour in the belief that taking part in a  
trial means they will be protected.  

Prophylactic vaccine 
Many researchers are worried that all the effort being ploughed  
into developing therapeutic vaccines could detract from the search  
for a prophylactic vaccine (see sidebar). Others believe that  
progress towards one will help progress towards the other.  
Valentine, for example, says he thinks the search for a therapeutic  
vaccine would strengthen work on a prophylactic vaccine. "If you  
could get a biological effect in individuals who are infected, it would  
spur on efforts to get a prophylactic vaccine." 
But can we assume that something that works therapeutically will  
also work prophylactically? Alan Schultz, acting chief of vaccine  
research and development at the National Institute of Allergy and  
Infectious Diseases in Bethesda, Maryland, says: "Just because a  
vaccine product may show therapeutic benefit, I am not sure that,  
on its own, makes it a lead candidate for a prophylactic vaccine. If  
you are infected, you already have a vigorous response to HIV. So a  
50 microgram dose could be efficacious as a therapeutic vaccine,  
but it could take perhaps 50 times more to achieve a prophylactic  
vaccine." 

'Chalk and cheese' 
Jonathan Weber, professor of communicable disease at St Mary's  
Hospital Medical School in London, says classical immunology  
suggests that the mechanisms by which a viral infection is  
prevented are quite different from the ones that control it.  
Neutralising antibodies are crucial for protection. Prophylactic  
vaccines, mostly derived from viral envelope subunits, aim to  
stimulate such antibodies, but, Weber says, it is hard to see a role  
for neutralising antibodies once someone is infected. By contrast,  
cellular immunity is needed to control infection once it has taken  
place. "You are comparing chalk and cheese." 
He says he has seen no data at all so far that suggests that  
therapeutic immunisation is effective. "For me, it remains wishful  
thinking - wishful thinking that I nevertheless strongly support." 

------------------- 
Sidebar: Vaccine research:  
is there a cuckoo in the nest? 

Is there a risk that the desire to develop therapeutic vaccines could  
drain energy and resources from programmes aimed at developing  
prophylactic vaccines? Steven Basta, director of investor relations  
and market development at the Immune Response Corporation,  
which is testing the Salk whole killed virus prepration in 103 HIV- 
infected individuals, illustrates how that pressure is operating. 
He says: "There are 10 million infected people out there. That is  
the critical human need which is driving the scientific community  
to develop a treatment for this life-threatening epidemic."The same  
urgency does not exist for the development of a prophylactic  
vaccine: "Someone who is not infected does not have a terminal  
illness." 
Plenty of researchers fear that the result could be to detract from  
the efforts to develop a prophylactic vaccine. 
Gordon Ada of the John Curtin School in Canberra says: "It would  
not be good if that were to happen. You have to look to what is the  
future of a country and the future of the country is people who are  
not yet infected. You should do what you can for infected people,  
but it would be a retrograde step if it did significantly interfere with  
attempts to developt a prophylactic vaccine ." 
Jonathan Weber, professor of communicable disease at St Mary's  
Hospital Medical School in London, agrees. "I think it's a tragedy.  
Every vaccine company is quite preoccupied with therapeutic  
immunisation when they should be totally preoccupied with the  
prophylactic work. The priorities are wrong at the moment." 
Weber points out that the market for a therapeutic vaccine is  
immediate and First World - the kind of market that a  
pharmaceutical company could expect for a new drug. By contrast,  
the market for a prophylactic vaccine for HIV in the developed  
world is about as large as that for the hepatitis B vaccine: health  
care workers, anyone who is at risk sexually.  
As in the case of the hepatitis B vaccine, while the market in  
developing countries would be much larger, these countries would  
not be able to pay the vast sums that pharmaceutical companies  
would argue they need in order to reimburse them for their  
development costs. 
Alan Schultz, of the National Institute of Allergy and Infectious  
Diseases, asks, "Even if we had the data that there was an AIDS  
vaccine as successful as measles and mumps, who would take it?  
Most straight people would say, I'm not at risk and I certainly  
would not give it to my children." 
There is a risk, he agrees, that so much money may be sunk into  
developing a therapeutic vaccine that there will be less left over for  
work on a prophylactic vaccine. But at least the "carrot"of the  
market for a therapeutic vaccine may keep some biotechnology  
companies in the field for longer than if they were only looking at  
the market for a prophylactic vaccine, he says. 

********************************************************** 
Drug legalization: A matter of public health and human rights 
Legalise illicit drugs? The idea seems crazy at first; with the all  
violence and corruption already associated with drugs, the suffering  
of many users and their families and, most recently, the clear link  
of AIDS to addiction. Why would you want to make it easier to get  
drugs? 

(article continues in part 3) 
--- GEcho 1.00/beta 
 * Origin:  (2:280/413) 
************************************************************************
************************************************************************
Msg#:27234 *Int'l AIDS/ARC* 
07/21/92 22:36:00 
From: MATTHEW LEWIS 
  To: ALL 
Subj: REPLY TO MSG# 27233 (CONFERENCE NEWSPAPER - TUESDAY 21 JULY - PA) 
CONFERENCE NEWSPAPER - Tuesday, 21 July - part 3 of 4 

(continuation of article from part 2) 

The answer is not simple, but the starting point is the notion that it  
is our drug policy, not the drugs themselves, that accounts for the  
problems. 
Public health is still not a serious consideration in formulating  
international drug policy. The dominant social response to drug use  
and drug users is repression and, in the name of drug enforcement,  
many basic human rights are violated. This subject will be discussed  
at today's Round Table on Drug Addiction and Human Rights  
(Session 84), but here are a few actual examples: 

*In Bavaria, a young heroin addict finally gets on methadone, giving  
him a new lease of life. But the state prosecutes the doctor and  
stops the prescription of methadone for the addict, who hangs  
himself in despair. 

*In Malaysia, a young American who uses marijuana to relieve  
chronic back spasms associated with a teenage climbing accident is  
sentenced to death for possession of 280 grams. 

*In Rockford, Illinois, in the US, a young woman whose child dies  
shortly after birth is prosecuted for attempted murder because  
traces of cocaine were found in the baby's system. 

Such harsh and punitive responses destroy the potential for  
effective intervention by stigmatising and marginalising drug users.  
Instilling fear and distrust in drug users, prohibition undermines  
basic public health efforts to limit the AIDS epidemic: early  
identifica-tion and access to compassionate treatment and AIDS  
education. 
More directly, the War on Drugs robs scarce resources from drug  
treatment and AIDS prevention. Since 1970, the US has spent  
more than $500 billion dollars on prosecuting and imprisoning  
drug users: the cost for 1992 alone will exceed $50 billion. No  
wonder there is nothing left for the social programmes needed to  
solve the problems underlying widespread addiction, such as  
poverty, unemployment and social dislo-cation. Further, local drug  
economies operate to remove wealth from the poorest  
communities. 
It would be appropriate - even cost effective - to heavily  
"capitalise"a public health approach to drug problems.  
Such an approach would include vastly expanded treatment,  
lowering the threshold for seeking care and increasing the  
likelihood of re-entry into drug treatment in the event of relapse,  
and education directed toward responsible use of all drugs - but  
accepting recreational use as the norm it is. These programmes  
could be easily funded by the savings associated with an end to drug  
prohibition.  
Every time we arrest and incarcerate a young drug user, we commit  
ourselves to a lifetime cycle of relapse and re-arrest, and a long list  
of health and social costs borne by the public - AIDS being only the  
most recent. In the US we spend more than $500,000 on these  
punitive approaches in a user's lifetime. Wouldn't it be better to  
"invest"even a quarter of this amount for effective treatment and  
rehabilitation, education, job training and social assistance? 

Ernest Drucker, director, Division of Community Health,  
Montefiore Medical Center/Albert Einstein College of Medicine 

********************************************************** 
HIV and STD prevention: something works! 
It is now accepted that the presence of other STDs increases the  
risk of transmission of HIV. Newer information suggests that HIV  
also prolongs the infectious period of other STDs, setting up a  
dangerous synergy. So efforts to prevent the spread of HIV need to  
incorporate treatment for STDs. They also need to take into  
account the true sexual behaviour of people in a given community.  
Use of trained local workers is essential. 
In two community-oriented programmes among sex workers in  
Nairobi and Kinshasa, a combination of these strategies has proved  
effective. Through peer counselling, comprehensive STD care, as  
well as negotiating and role-playing strategies, rates of condom use  
have been substantially increased and the incidence of HIV  
transmission has been greatly reduced.  
William Check reports. 

Marie Laga:  
Putting knowledge into practice 

An HIV prevention programme among prostitutes in Kinshasa,  
Zaire, achieved a "quite dramatic"decrease in the HIV transmission  
rate over a two-year period. The project, organized by Dr Marie  
Laga, assistant professor of microbiology at the Institute of Tropical  
Medicine in Antwerp, incorporated several important principles:  
attention to HIV and other STDs; use of trained workers from the  
local community; and empowerment of the target population. 
The project, conducted in collaboration with the US Centers for  
Disease Control, US National Institutes of Health and the Zairean  
government, first determined the prevalence rates of HIV and  
other STDs among prostitutes and surveyed local sex workers'  
knowledge of and practices for preventing STDs and HIV. The  
prevalence of HIV infection was 37%, syphilis 25%, and gonorrhoea  
20%. "Three out of every four women had at least one STD,"says  
Laga.  
"What was striking was that knowledge about STD prevention was  
good, but behaviour was not. Fewer than 5% used condoms  
regularly. Many used traditional methods to protect against STDs,  
but very few used effective methods." 
Laga then examined the impact of an educational intervention  
which combined monthly check-ups and treatment of STDs with  
promotion and distribution of free condoms. In addition, the  
women attended individual counselling and education sessions and,  
every three months, a group session, all conducted by trained local  
nurses and a sociologist. Advanced sessions focused on how they  
could negotiate with men who did not want to use condoms.  
At the outset, the annual incidence rate of HIV infection was 25%;  
two years later it had dropped to 4%. "This is indirect proof that if  
you promote condom use intensively you really can reduce the rate  
of new HIV infections in a group that is at high risk,"says Laga. 
Many people ask, which played the greater role - condom use or  
STD treatment? Laga believes it was the synergistic combination of  
the two. "If you provide good health care, women listen better to  
the preventive messages." 
But even after two years, only about half the women said they used  
condoms all the time, because men often refuse. "That's a universal  
finding,"says Laga. One alternative would be to promote the use of  
"female-controlled methods", like the female condom. "It has pros  
and cons. Men know it's there, but do they object to it? Studies are  
needed to answer that question." 
Traditional spermicides are another alternative. In vitro, they act  
against viruses. "Unfortunately limited studies up to now have  
shown that when spermicides are used at high frequency, several  
times per day, as a prostitute would do, they seem to cause side  
effects that may put women at higher risk for acquiring HIV, rather  
than protecting them."These side effects include irritation and  
erosion of the vaginal mucosa. So current spermicides may not be  
useful for high-frequency use. 

Tony Klouda:  
Combat at the community level  

"Without a shadow of a doubt, the majority of STDs are either  
treated or recognised outside the formal health care system,"says  
Dr Tony Klouda, coordinator of the AIDS Prevention Unit for the  
International Family Planning Foundation in London. While this  
pattern is most prevalent in developing countries, STD services in  
developed countries are also underused, especially by women, due  
to a failure to recognise STDs and the shame associated with having  
one, Klouda says.  
Klouda hopes to encourage more people into standard treatment by  
helping family planning associations (FPAs) to see the importance  
of recognising and diagnosing STDs, not only within the  
associations' clinics, but also among street traders, traditional  
healers and other people in the community whom people ask for  
advice on STDs.  
Klouda's second goal in preventing transmission of sexual diseases,  
including HIV, is to understand better people's sexual lives. Only by  
acknowledging facts - that some people have multiple sex partners;  
that some people use sex workers; that young people experiment  
with sex from an early age; and that old people also have sex - will  
effective STD control strategies be devised.  
Both priorities require an interaction with communities that is  
quite hard to achieve, says Klouda. But while participation of local  
communities is standard in community development work,      it is  
less common in family planning projects.  
He believes it is important to establish local means of coping with  
STDs using methods of research that involve local people, rather  
than formal surveys. What is necessary is to develop contacts in the  
community and then train standard health care workers  
(physicians, nurses, epidemio-logists) to be sensitive to the beliefs  
and practices of local people. 
The goal is to identify what is already done in a community and to  
improve it rather than trying to change it. "It may be that street  
traders are handling antibiotics and doing it badly. What I would  
like to concentrate on is training them so that they can recognise  
and treat STDs better, while realising the realities of the situation,  
such as their commercial interest." 
The traditional motivations for FPAs to work in this field -  
preventing loss of fertility from pelvic inflammatory disease - may  
not apply to HIV. "The key issue for family planning has always been  
establishing safer sex,"says Klouda. "Until recently this has meant  
sex safe from pregnancy. Now we need to work for sex that is also  
safe from disease and safe from the abuse of power in sexual  
relationships. That means sex that is pleasurable." 
Klouda says: "Many women throughout the world are in no position  
to say what their partners do to them sexually or what their  
partners do with others sexually."One solution is groups which help  
women to negotiate more effectively with their partners or with  
men in general.   
"HIV is a development issue,        not just a medical problem that  
can be isolated from economic and social factors endemic in the  
community,"he says. 

Elizabeth Ngugi: 
Changing sex workers' attitudes 

Dr Elizabeth Ngugi, lecturer in the department of community  
health at the University of Nairobi, Kenya, attempts to prevent STD  
transmission by encouraging sex workers to use condoms with  
their clients. Her programmes focus on community beliefs and peer  
counselling. 
At the beginning of her project, Ngugi surveyed men, women and  
youth from the local community to determine what they knew about  
STDs. They knew that they could get conventional STDs and that  
these infections were curable. But knowledge about HIV was less  
accurate. "When we ask, +Do you think you are vulnerable to getting  
AIDS,"says Ngugi, "the answer is usually, +Well, I don't think so'." 
She thinks that is denial and that people are trying to rationalise a  
contradiction: that HIV, a fatal disease, can be transmitted through  
sex, which is procreative and gives life.  
Two main strategies have been incorporated into the project. "We  
get them to do role-playing. And we get some of them who are now  
infected, who did not believe that if they did not change their  
lifestyle, they could get infected, to come back as peer  
educators."In effect, these peer counsellors say, "We should have  
changed our sexual behaviour. Now we are infected. And we cannot  
blame anyone."Ngugi focuses her project on the target community:  
"Going where people live and work is what will give us better  
coverage."The programme also tries to reach people when they go  
to hospitals or clinics to be treated for an STD. For those patients  
who are confused about how STDs are transmitted, the hospital- 
based part of the programme provides an educational and  
reinforcement opportunity. 
Significantly, the programme is also designed to address issues of  
procreation and power. If people of either sex think they will lose  
status by not conforming to social norms, they are less likely to  
change their behaviour. 
To counter this fear, counsellors encourage the sex workers to  
change their attitudes about themselves. They tell people: "You are  
not able to negotiate when you are sick. Being healthy gives you the  
power to negotiate." 
The women well understand that they cannot continue working if  
they are sick: therefore many of them now use condoms. Within a  
year, the number of sex workers in the programme who always use  
condoms went up from 4% to 32%. Of those who have been in the  
programme longest, 50% always use condoms and another 10% use  
condoms some of the time. 
"That is an important achievement,"says Ngugi.   
Although unexpected, there is now a healthy debate among men  
and women about condoms, which may increase their acceptability.  
The programme held several meetings for men to talk among  
themselves about their sexual lifestyle. Without the knowledge of  
the programme staff, the men invited some women sex workers.  
The men blamed the women for not telling them about condoms;  
the women blamed the men for not letting them use condoms.  
Although the initial exchange was about blame, at least it set the  
stage for a healty and valuable debate, says Ngugi. 

Photo caption: A health worker in Singapore testing for gonorrhoea  
- a disease that facilitates the spread of HIV 

Photo credit: WHO/T. Farkas 

(article continues in part 4) 

************************************************************************
************************************************************************ 

Newsgroups: sci.med.aids