From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference newspaper - Monday, part 2
Note: non-commercial reproduction.
Archive-Number: 5736
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 20 Jul 92 20:29:30 GMT

CONFERENCE NEWSPAPER - MONDAY, PART 2

(continuation of article)

The conference has brought more and more diverse 
participants from developing nations and Asia, eventually 
creating a network of 23 regional contacts throughout Asia, 
Africa, and Latin America. Rao says: this was accomplished 
through sheer persistence: by phone, by fax, by any means 
available. Organisers hope their persistence will set the 
standard for future conferences. 
There have been complaints that the conference lags 
slightly behind in the reporting of scientific data. 
Because abstracts must be submitted as much as six months 
in advance and because AIDS science is moving so quickly, 
the most up-to-date information in past conferences has 
been presented in press conferences rather than in actual 
conference sessions. The organizers this year accepted 
abstracts up until July 1 for possible presentation in 
specially designated "recent report" sessions.
Innovation
Perhaps the greatest innovation of this year's conference 
scheduling is getting more balanced representation of 
social issues and basic science. Of the 968 speakers at 
this year's conference, 197 will present basic science, 191 
clinical science and care; 174 epidemiology; and 184 social 
impact and response, says Rao. The evening mini-courses 
will provide the opportunity for experts in especially the 
social science and clinical fields to discuss the 
theoretical issues they face in finding practical answers 
to the problems faced by educators and care providers.

********************************************************
Effort to mobilise youth against AIDS
by Simon Rozendaal

During this year's AIDS conference, 15 young people will 
take the first steps toward mobilising the youth of the 
world in the fight against AIDS. Aged 15 to 25, the young 
people, from Morocco, Canada, Switzerland and other 
countries, were selected by UNESCO and invited to attend 
the Amsterdam conference.
The group is comprised of people with different 
backgrounds, including students, homosexuals and HIV-
infected people. They will have a round table discussion, 
"The Response of Youth to AIDS", on Thursday at 09.45 
hours. To prepare for that discussion, the 15 will meet 
twice, getting to know each other and talking about their 
involvement in the battle against AIDS. 
UNESCO has proposed that the group prepare a youth charter, 
which could be presented to the president of the 
conference.
Gert Jan Rietveld from the Netherlands, one of the 
participants, 
welcomes the initiative. "Up until now international youth 
organisations have not been very successful in discussing 
AIDS on a regular basis," he says. "There are too many 
different angles. Christian youth groups look at AIDS in a 
different way from young homosexuals or young socialists."
Rietveld. "About two months ago UNESCO started inviting 
us." He 
expects that one suggestion from the group might be to have 
a special youth delegation at the next conference on AIDS. 
"That is 
to say, if we come to the conclusion that AIDS poses 
special 
problems for young people."
An important topic probably will be sex education at 
secondary 
schools. Says Rietveld, who stopped his university studies 
for a year to work in a Dutch youth organisation, "Many 
young people are 
vulnerable because they know too little. I myself only knew 
before I got involved that as long as you used a condom 
there was no need to worry about AIDS. I didn't understand 
the reason why I had to use a condom." 

*********************************************************
Everything you ever wanted to know about oral sex...but you 
won't find it here 
By Robin Gorna

"Is oral sex safe?" That's the question on everyone's lips. 
People with HIV want to know, prevention workers need to 
know, epidemiologists don't know whether to consider it, 
and researchers simply don't have the answers. Some 
activists wonder: "Are they even trying to ask the 
question?".
Researchers can study the efficacy of HIV transmission in 
two ways: through basic scientific research and by 
extrapolating from the past behaviour of people now 
infected. 
Such studies have shown that both HIV-infected cells and 
free virus can be present in blood, semen and cervical 
secretions in sufficient quantities for transmission to 
occur. But although it's natural to assume that ingestion 
means infection, is that the case?
"No data"
Research has established two significant factors that may 
help to answer this question. First, gastric acid can 
neutralise quantities of the virus much greater than those 
which would be necessary for transmission. Saliva also has 
a neutralising effect on HIV. However, according to Dr 
Richard Marlink, executive director of the Harvard AIDS 
Institute in Boston, Massachusetts: "Antigen-presenting 
cells, and even CD4 cells, may be present in the mucosal 
tissue of the mouth, which may make it susceptible to 
infection. Infection may also be possible if the natural 
mucosal barrier to infection is incomplete due to open 
wounds or inflammation. It is important to note, however, 
that these are theories, we have no data to back up either 
school of thought." 

Dr. Matthias Wienold, head of medicine and health politics 
at Deutsche AIDS Hilfe in Germany says: "We only have 
evidence on theoretical grounds that swallowing semen 
increases the risk - because it's in the oral cavity for 
longer." 

Biological determinants
Where theory is so unpersuasive, a multi-disciplinary 
approach should help provide the answers. Dr Anne Johnson, 
senior lecturer in epidemiology at University College and 
Middlesex School of Medicine in London says: 
"Epidemiologists need to work hand in hand with virologists 
in understanding the biological determinants of HIV 
transmission." 
Given that most people's sexual repertoire involves more 
than one activity, it is unlikely that just interviewing 
people with HIV will confirm the efficacy of oral sex as a 
mode of transmission. If a person with HIV has engaged in 
two practices, one of which is known to be of higher risk 
(for example, both anal and oral sex), then the higher-risk 
activity will inevitably be identified as the route of 
entry. 
Worldwide, there have been no more than 20 case studies 
suggesting either fellatio or cunnilingus (usually during 
menstruation) as the only route of HIV transmission. 
However, Wienold says: "These are usually very individual 
studies and it's unclear how reliable they are. There is no 
significant epidemiological research." 

Challenge
He says larger studies tend to suggest no correlation 
between oral sex and transmission. In the absence of 
definite answers, the challenge to health educators is 
immense. And they are meeting the challenge differently 
around the world. One American doctor says: "As long as the 
evidence is inconclusive, I have to tell HIV-positive women 
that they need to use dental dams for cunnilingus - I can't 
risk their partner's becoming infected and sueing me." 
Others, particularly Europeans, claim that effective 
education hangs on more than a theoretical risk. Rainer 
Schilling, a health educator at Deutsche AIDS Hilfe, 
explains: "If you say nothing's safe, people do everything. 
Differential risk
"We have to explain the differential risk. If you say: TYou 
must use a condom', and people don't like the taste, then 
they won't use a condom and don't even take care not to 
swallow semen. We say: oral sex is somewhere between 
"safer" and "safe" sex, semen is more risky than pre-cum, 
it's OK to suck without a condom if you don't swallow. 
Ultimately it's an individual's decision how much risk they 
accept."
The problem is, none of us know how small - or big - that 
risk really is. If you thought you'd find the answer in 
Amsterdam this year, regrettably you won't. 
Key question
Holly Ladd, of the Community Liaison Committee, explains: 
"We said oral transmission was a key question in 1992. But 
when we were reviewing the abstracts there were only two. 
Regardless of their quality, it just couldn't be a session. 
It would be a shame if we walked out of the conference 
saying TBecause there was no oral session on oral sex, it's 
not important'. This must remain a key question for 1993."

----------------------------------
"It's a problem for me now, how it influences my sexuality. 
It's also a fear that I'll infect my partner. What really 
happens when you practice cunnilingus? It's all so 
unclear." 
(Tanja, HIV+ since age 19).
------------------------------------------------
*********************************************************
AIDS research: The unanswered questions

The International AIDS Conference brings together 
researchers, health workers and policymakers whose 
questions cross disciplines and continents. The conference 
is an opportunity to catch up on the latest information in 
a range of fields and to reflect on the distance research 
still has to go. Many questions have been answered, but 
many more remain. World AIDS News asked more than a dozen 
people coming to the conference: what are the most pressing 
unanswered questions in HIV research and policy?

Lars Kallings, Global Program on AIDS, WHO, Geneva:
What other possibilities in addition to the condom exist to 
stop heterosexual transmission?
Can better and cheaper virucidal and vaginal substances, 
applicable many times a day without causing inflammations, 
be developed?

Carol Levine, The Orphan Project, New York:
What is the impact of HIV/AIDS on family structure, 
especially when children and adolescents survive a parent's 
death?

Marc Girard, Pasteur Institute Paris:
Why is the virus not knocked out by the cytotoxic 
lymphocytes, which are very active against HIVin vitro?
Why don't chimpanzees and other primates develop disease 
after HIV infection and man does?
How can we induce a neutralising antibody response that is 
strong enough and lasts long enough to provide protection 
against HIV after only one injection?
How many different viral strains must be represented in a 
multivalent vaccine?

Anneke van den Hoek, Municipal Health Service, Amsterdam:
Why is the progression from infection to AIDS the same in 
drug-addicts, even though they are infected repeatedly and 
do not sleep or eat properly?
What is the reason behind and the importance of the recent 
lapse from safe sex among homosexuals in Europe and the US?
Why does one infected person get AIDS after two years and 
another after ten years or even more?

Praphan Phanuphak, Thai Red Cross, Bangkok:
What is the most effective way to persuade politicians and 
policy-makers to commit themselves to the prevention and 
control of AIDS?
How can we protect the rights of HIV-infected persons in 
employment, housing, education, etcetera?
How do we get people to realise the importance of AIDS, so 
that they change their risk behaviours?
Anthony Pinching, 
St Bartholomew's Hospital Medical College, Londen
Do CD4-cells get depleted because the virus is cytopathic 
or because the host is getting rid of virus-infected cells?
Why do the remaining, uninfected, CD4 cells function 
poorly?
Are nerve cells lost from the brain in infection and, if 
so, how?
What is the role of antigen-presenting cells, such as 
monocytes and macrophages, in passing the virus around?
What biological markers will better predict the course of 
the disease?
How much do asymptomatic HIV-infected people benefit from 
antiretroviral treatment, and how long does this benefit 
last?
How can we best achieve primary (as opposed to secondary) 
prevention of opportunistic infections?

David Serwadda, Mulago Teaching Hospital, Kampala:
How variable are strains of HIV from different parts of the 
world and what implications do these variations have for 
vaccine development?
How can we develop methods to evaluate which AIDS 
intervention and health education programmes are effective?

Malcolm Potts, International Family Health, London:
Is circumcision a factor in the transmission of HIV?
What are the relative costs and benefits of education, 
prevention of STDs and condoms in AIDS-prevention?

Anne Johnson, University College and Middlesex School of 
Medicine, London:
How does variability in viral load correlate with 
infectivity in vivo and how can this be studied in 
prospective studies? 
What is the relationship between viral load in blood and 
viral load in genital secretions? Does treatment of STDs 
reduce the genital viral load? Do antivirals reduce it?
Why has more effort not been put into new acceptable 
virucidal agents and barrier methods like the female 
condom?
Are there people with HIV who never get AIDS? If so, why?

Maxine Ankrah, Makerere University, Kampala:
To what degree is the spread of HIV attributable to 
poverty?
Can changes in sexual behaviour be sustained without 
changes in the personality of individuals?
Can HIV-1 and HIV-2 mutate into even more deadly viruses?

Ibra N'Doye, National AIDS Control Programme, Senegal:
Which strategies can be used to prevent the spread of HIV 
as a result of migration?
Are the African states ready to deal with ethical and legal 
problems of AIDS in the future?

Frank Miedema, Central Laboratory for Blood transfusion, 
Amsterdam:
How important is latent virus in monocytes, given the fact 
that this does not happen in chimpanzees?
How is it possible that 50 percent of people with AIDS get 
ill without having been in touch with the more aggressive, 
fast-replicating, viral strains?
Are we using the right viral strains in making vaccines?
Do long-term survivors have a special genetic make up?

Claire Rapaport, San Francisco General Hospital:
Is combination antiretroviral therapy better than single-
drug therapy? If so, when should combination therapy be 
initiated? 
Which gynaecological conditions are truly indicative of HIV 
infection?
What is the natural history of HIV in women? 
How can we address and manage the entire complex of 
problems around HIV, both medical and psychosocial, 
including substance abuse, homelessness, childcare for 
families and caretakers, taking into account whatever 
belief systems patients have about health?   

Joost Ruitenberg, Central Laboratory for Blood Transfusion, 
Amsterdam:
How can blood and blood products be made available in a way 
that is safe  and affordable to everybody throughout the 
world?
Is there a difference in the progress of the disease 
between men and women?

Gina Brown, Columbia University College of Physicians and 
Surgeons: 
What are the benefits and risks of treating an HIV-positive 
woman with antiretroviral therapy during pregnancy?  Does 
it decrease vertical transmission? Is there any long-term 
benefit to the mother? When and how does vertical 
transmission occur? Can it be prevented? 
What are the differences between foetuses that become 
infected in utero and those that do not? 
How confident can we be that breastfeeding by HIV-positive 
women is safe?
Is it possible that the high rates of perinatal 
transmission that we see in Africa are at least partly a 
result of breastfeeding?

Ian Campbell, Salvation Army, London:
How can traditional values and beliefs in a community be 
mobilised for a programme of caring for AIDS patients?
How can international organi-sations, who often say they 
are interested in AIDS, be inspired to take the lead? 

Peter Piot, Institute of Tropical Medicine, Antwerp:
Could we develop products that protect women from 
infection?
How can we develop simpler, less-expensive methods to treat 
STDs in women in developing countries?
What causes disease in people infected with HIV? 

-- 
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