From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference newspaper - Friday 24 July - part 3
Note: non-commercial reproduction.
Archive-Number: 5786
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 26 Jul 92 17:16:46 GMT

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Hopes for immunotherapy
By Wim Zeijlemaker

Many researchers are looking at   the usefulness of passive 
immunotherapy: infusions of antibodies purified from the blood of 
HIV-positive people who are healthy into those who are sick. Many 
questions about this remain unanswered, as became clear in 
Wednesday's round table session on the subject. 
We know that well-defined anti-HIV antibodies can be obtained. 
Most neutralizing antibodies described so far are directed against 
the V3 loop or the CD4-receptor site. For passive immunotherapy, 
classical human serum immuno-globulins may be used. 
Dr Abraham Karpas, of the University of Cambridge in the UK, told 
the session about successful placebo-controlled passive 
immunization of HIV patients with classical, hyper-immune 
polyclonal human serum antibodies. As a result, levels of the virus 
in patients fell to undetectable levels.
For passive immunotherapy, there  is now an alternative to  
polyclonal antibodies: several human mono-clonal antibodies against 
HIV antigens are available. 
However, the main advantage of monoclonals, their defined 
specificity, is at the same time a drawback: the virus may escape 
antibody-neutralization by the appearance of variants, as several 
researchers have already shown. An obvious way out will be to use 
mixtures of monoclonals. 	Immediate targets for passive 
immunotherapy with antibodies are laboratory needle-accidents and 
maternal-foetal transmission.
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Research into women and AIDS: where is it?
by Robin Gorna

Anna, a 27-year-old health care worker in Oslo, Norway, has had 
chronic, persistent vaginal candidiasis for five of the six years since 
she was infected with HIV. The doctors she sees have never 
examined her: "I have a feeling they're a little bit embarrassed. I 
just say I have something itchy and they write a prescription." She 
has never been advised about cervical smears (PAPs) and has never 
had one.
Tanja, a 26-year-old student from Stttgart, Germany, finds that 
she gets far more acute and depressive bouts of premenstrual 
syndrome since her infection, but the doctor who is looking after 
her HIV infection has never asked about menstrual or 
gynaecological problems (nor suggested cervical smears) and she 
has not raised them. "When you first get your diagnosis, you're so 
frightened. I kept thinking 'Maybe he'll ask me about my periods so 
I can find out what's going on'."
Josephine, who works at the British support group Positively 
Women, has heard many other HIV-positive women describe 
problems such as periods stopping, bad pain or heavy bleeding 
during periods and vaginal candidiasis. She says: "We must have 
more research and guidance on cervical cancer, pelvic 
inflammatory disease (PID), the effect of HIV on periods and what 
happens when you take antivirals together with the contraceptive 
pill or hormone replacement therapy."
The Community Liaison Committee for this conference  called a 
meeting of women clinicians, researchers, women with HIV and 
community activists in November 1991 to participate in the 
planning process. Holly Ladd, who sits on the committee, says she 
was surprised at the degree of consensus about what the key 
questions were for women "and by what we know and what we 
don't know in order to meet the needs of women in the middle of 
the epidemic". She says the issues included: Are there gender 
differences in clinical manifestations? What are the appropriate 
treatment regimens? Are there differences in survival? How do we 
ensure access to care for women affected and infected throughout 
the world?"
Studies presented here, in Session 67, show high levels of 
abnormal cervical smears in women with HIV, ranging from mild 
dysplasia to cervical intraepithelial neoplasia. The prevalence 
ranges in these surveys from 25% of 135 women in Rhode Island 
(in an unpublished study by Dr. Kenneth Mayer), to 62% of 29 
women in Maryland and 31% of 55 women in New Jersey. In the 
Bronx, New York, a study by Anastos found abnormal smears in 37% 
of 132 women, and found a further association between advanced 
cervical cytologic abnormalities and advanced HIV disease. 
Where there is a control group, rates of abnormal smears have been 
found to be higher than in women who are uninfected. The study by 
Faye/Ndao of 102 women in Dakkar, Senegal, shows increased rates 
of cervical dysplasia in women infected with HIV-1 and HIV-2 
compared to seronegative controls. Similarly, in another study in 
the Bronx, researchers found squamous intraepithelial lesions (SIL) 
in 25% of women infected with HIV, compared to 10% of those 
who were not. A study in Malawi found that 13% of HIV-infected 
women (n=128) and 6% (n=158) of uninfected women have SIL. 
This study shows the same trend as that by Anastos: higher rates of 
SIL with increased immunosuppression. Despite these higher rates 
of cervical abnormalities, the studies indicate that, with standard 
gynaecological care, rapid progression to severe invasive cancer is 
uncommon.  
Most of these studies recommend surveillance for cervical cancer 
in women with HIV. The need for common protocols on the 
frequency of cervical smears seems clear. While assertive women 
demand them every six months, many others can only get checked 
every three years. Women clinicians and researchers, confirm the 
need for a new protocol but caution that not enough is known yet. 
Dr Anne Johnson, senior lecturer in epidemiology at University 
College and Middlesex School of Medicine in London, says: "We 
need to understand better whether conditions such as cervical 
cancer and vaginal candidiasis are markers of severe immune 
deficiency, in order to confirm the necessary treatment and 
diagnosis. 
One of the problems is that the epidemiological profile of women 
with HIV and with cervical cancer is similar. According to Dr 
Deborah Cotton of Harvard University in Cambridge, Massachusetts, 
"The risk factors tend to be the same: women having early sex, and 
women with multiple partners." 
Some activists will find in the data presented this year further 
evidence for including cervical cancer, PID and vaginal candidiasis 
in the AIDS definition. Yet a number of scientists remain 
unconvinced. They say that such conditions should only be included 
if they can be demonstrated to occur with very much greater 
frequency at levels of severe immune deficiency, and to carry the 
same prognostic value as other AIDS defining conditions. Without 
this certainty, they believe, there is a risk of falsely labelling women 
as having a diagnosis of AIDS. 
Confused
Indeed, some claim that clinical issues, epidemiology and politics 
are becoming confused. The AIDS definition has a number of 
purposes. For epidemiologists, the AIDS definition is a tool to help 
chart accurately the progress of the epidemic. But for infected 
people the effects of diagnosis are mixed. On one hand there is the 
psychological impact of knowing the severity of their condition. But 
in some countries, an AIDS diagnosis may also enable them to gain 
better access to care and social benefits. 
Cotton and Johnson insist that without extensive, co-ordinated 
multi-centre studies the true clinical situation for women with 
HIV/AIDS cannot be described.
"We don't compare haemophiliacs with gay men," says Johnson. "In 
the same way we must have proper cohort studies of women, like 
we have of men. Recent studies have suggested that there are no 
major gender-specific differences in AIDS defining illnesses, but 
right now we don't have good longitudinal research to examine 
specific outcomes for women, particularly gynaecological conditions 
for women."
Such cohort studies would also help to determine whether there is 
a difference between the sexes in progression of disease and 
survival rates. In general, studies have shown a shorter life 
expectancy for women than for men (respectively 20.1 and 24.2 
months with antiviral therapy; and 8.9 and 13.3 months without, 
according to one American study. The question that such data raise 
is to what extent this reveals a biological difference in survival 
rates, or whether this is due to social factors, like differences in 
access to care.
Data presented here in sessions 14 and 26 Gender-Related 
Variations in Natural History and Natural History of HIV Infection in 
Different Groups, support the thesis that social factors are to blame. 
Studies of women who have access to medical care and/or clinical 
trials consistently show no significant difference in disease 
progression, development of opportunistic infections and survival 
when compared to men. Significantly, studies have consistently 
shown that the survival rates in the US for people of colour are less 
than for whites; and those for drug users are less than for gay men. 
Women, people of colour and drug users all tend to have more 
limited access to care.
Johnson says: "The explanation may not be intrinsic to women, but 
may be due more to late diagnosis and quality of access to care." 
Cotton says: "The differences in access to care between women and 
men are so great that they are a more likely explanation than 
biological differences."
The difficulties for women in gaining access to care seem to be 
universal. According to Marge Berer, co-editor with Dr. Sunanda 
Ray of the forthcoming Women and HIV/AIDS - An International 
Resource Book (London: AHRTAG): "Lack of food is probably killing 
women as fast as anything. How can they afford to eat when they're 
too ill to work, they've been dismissed from their jobs or 
abandoned by their husbands? One of the few things a clinic in 
Ghana can give the women is food and very little of that."
In Zimbabwe, Sunanda Ray finds that the limited access to care and 
treatment is intensified further for women. "Our health system is 
changing so that people are having to pay actual costs," says Ray. 
"Often, a woman doesn't get the money from her family to pay for 
her health care."
And costs are prohibitive. At around $50, the HIV test costs a third 
of the monthly wage for a woman engaged in manual work. Even 
those women who can afford medicine are often limited to inferior 
services relative to their male peers. Ray says: "They live in rural 
areas and so use rural or government clinics which are very busy. 
Whereas their husbands, if they work in industry, have better 
facilities at workplace clinics." Ray's findings that "women have 
inferior access to health care and they suffer with treatable 
conditions for longer" are echoed around the world. A quarter of 
the patients in Jrgen Poppinger's private practice in Munich, 
Germany are women, and they present for treatment late. He says: 
"They put up with far higher levels of pain and worse symptoms 
than men ever would."
Berer reports that surveys of Indian women in a rural district and 
among female sex workers in Bombay both showed rates of 
reproductive tract infections between 80 and 90%. A clinic close to 
the sex workers' district sees 100 men a day - but only 300 women 
a year. "Even where there are services, women won't use them," 
says Berer. "They're not being provided in ways that are accessible."
Johnson believes that there should be "good integrated facilities 
directed at women with HIV . . . ideally in one location so women 
can access everything in one visit." These would include general 
management of HIV infection, gynecological surveillance, obstetric 
and paediatric care, where appropriate, together with integrated 
psychosocial care including counselling, hospital creches and other 
child-care assistance.
By focusing on the questions, rather than the existing research, this 
Conference has raised issues yet to be addressed in such a forum. 
The overriding message remains that the current level and quality 
of research is insufficient to answer the most pressing questions. 
Ladd says: "It's imperative that this Conference sets a research 
agenda adequate to our needs."
Kate Thomson of the London-based group "Positively Women" says: 
"At Florence, the three sessions for us just felt tokenistic. This year 
looks a lot more hopeful but, at the end of the day, all we can see in 
the desert of women's research is a mirage." With 20 sessions this 
year addressing women-specific issues, we have the opportunity to 
turn that mirage into reality.

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Gender and power in developing countries
by Robin Gorna

"Caught between taboos, ignorance and a society that forgives men 
everything, and women next to nothing, women are often 
powerless to protect themselves, to impose their desires, their 
own demands," says Professor Hakim Himmich, president of the 
Morroccan Association for the Fight Against AIDS.
Men with heterosexual behaviour who do not use drugs are less 
likely to acquire HIV infection than women. But significant socio-
economic, political and cultural factors exacerbate women's risk. As 
Jonathan Mann, chair of this year's VIII International Conference 
on AIDS and III STD World Congress, puts it: "A male-dominated 
society is a threat to public health."
Explicit
In developing countries, the power structures which facilitate the 
spread of HIV are often explicit. For example, Marge Berer of the 
Women's Global Network on Reproductive Rights in the UK reports 
that a major focus of the Tanzanian self-help group WAMATA 
concerns legal rights over property. In order to keep property 
within a family, a wife is "taken over" by her brothers-in-law if her 
husband dies.

(article continues 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
Newsgroups: sci.med.aids