AIDS Breakthrough for Women
In this second WMC report on the XVIII International AIDS Conference in Vienna, Linda Villarosa explains why the development of a medicinal gel is both a lifesaving step forward for women and an affirmation of women and African Americans working to develop treatments.
A scientific presentation at a conference is generally a subdued affair. The room hushed except for a smattering of polite applause. Think early match at Wimbledon.
But the scene was wildly different last month at the XVIII International AIDS Conference in Vienna, when two South African researchers unveiled the results of a new study that showed that a gel containing antiretroviral medication was safe and effective in reducing a woman’s risk of being infected with HIV. Forget Wimbledon; think Yankee game in the Bronx.
About 1,000 people were crowded into a session room July 21 to hear that for the first time in history a topical medication, known as a microbicide, had prevented the spread of HIV. Hundreds more squeezed into an overflow room. Others were huddled in clumps in the hall outside watching video monitors—the overflow of the overflow. There was no polite applause; it was boisterous cheering.
“A standing ovation—you never see that at a scientific presentation,” said Dazon Dixon Diallo, the founder and president of SisterLove, a women’s reproductive organization that focuses on HIV/AIDS. Her group works out of Atlanta as well as South Africa where the microbicide research was conducted. “But it was a big win. For those of us who have been involved in microbicides for so long this is stunning. I have two words—woo ha!” The normally unruffled Dr. Anthony Fauci, one of the world’s preeminent and pioneering HIV/AIDS researchers, summed up his emotions in just one word at a press conference: “Amazing!”
The results of what is called the CAPRISA 004 trial, named after the center where the research was conducted, was the biggest news to come out of the six-day event, which featured some 20,000 activists, scientists, volunteers and journalists from 200 countries around the world. The Financial Times of London broke the press embargo and leaked the results, and a stampede of media with stories waiting in the wings followed suit.
The media frenzy was warranted: This microbicide gel could prove a game changer for women. The study of 889 uninfected women aged 18 to 40 in rural and urban KwaZulu-Natal, South Africa, found that the gel containing the HIV drug tenofovir cut infections by 39 percent. Among the women who used it consistently and correctly, the results were even better, 54 percent effectiveness. Either way you look at it, in the science world these numbers signal a major coup. The researchers also noted that herpes risk dropped by 51 percent, which was a surprise. The presence of herpes and other sexually transmitted infections increases the risk of transmission of HIV.
Though the results will need to be confirmed and a product won’t hit the market for at least a few years, this news marks a lifesaving step forward for women around the world. Globally, 33 million people are living with HIV, half of them women. In sub-Saharan Africa, where the epidemic is most dramatic and deadly, 22.4 million are living with HIV and every year millions more become newly infected. Women account for almost two-thirds of those living with HIV in the region, and young women, often poor and powerless, bear the brunt of the epidemic. South Africa has more people living with HIV than any country in the world.
Dr. Quarraisha Abdool Karim, who conducted the study with her husband, Dr. Salim Abdool Karim, described her frustration at not being able to offer protection to women who would come into clinics where she worked in South Africa. “When they asked us what can we do to protect ourselves, we had nothing to offer them,” said Dr. Karim, a Columbia University professor and associate director of the Centre for the AIDS Programme of Research in South Africa.
“Abstinence? They were married or in a stable relationship—no. Behavior change? They were faithful, but not sure about their partners’ faithfulness. Condoms? Men don’t want to wear condoms, and at the time there was no female condom.”
“So today,” she continued, “the results signal hope for women that they have something that is 39 percent more effective than nothing.”
Participants in the study were sexually active and applied the gel—half receiving the drug and the other half a placebo—both 12 hours before and 12 hours after sexual relations. It is inserted into the vagina using a plastic applicator. Sixty of the 444 women who used the placebo contracted HIV, compared to 38 of the 445 women who became infected after using the gel containing tenofovir. The area where the study participants come from is considered the “epicenter of South Africa’s explosive HIV epidemic,” where women engage in infrequent but very high-risk sex with migrant men. The product is colorless, and odorless—about the consistency of hair gel—so that a woman can use it without her partner knowing.
It's significant that half of the team that made this year’s discovery is a woman. Overall, at the biannual International AIDS conference women have had to fight for a seat at the table. Especially when it comes to the science of HIV/AIDS, the conference and the field have largely been a boys' club. This year conference organizers made sure that 50 percent of speakers on the high profile plenary sessions were women and included more events on topics like violence against women.
But young women and women living with HIV often struggled to make their voices heard. The day before the official proceedings began, Women ARISE (Access, Rights, Investment, Security, Equity), a coalition of groups around the world working to promote women and girls’ rights in the AIDS response, hosted a lively, free flowing discussion.
“I’ve been coming to this conference for 20 years, and I’m still distressed that women’s issues are marginalized,” Dr. Diane Riley said at the meeting. She is a professor at the University of Toronto and founding member of the International Harm Reduction Association. “We are totally pushed to the edge. I mean that literally: women are literally pushed to the edges of the day.”
Andrea von Lieven, a registered nurse and clinical program manager of medical affairs for the International AIDS Vaccine Initiative, spoke out openly for the first time about her own HIV status. “I don’t wish HIV on anyone, but I am proud to be part of the women’s village here,” said von Lieven, who is 46. “We must find a way to ease the burden on women, and we need the energy of young women. I don’t want to burn out. I want more women to chip in. I want to pass the torch,” she said.
As far as the microbicide study, it also mattered that the project was in the hands of two respected researchers of color. Many times, so-called scientific breakthroughs come with the uneasy feeling that the subjects in the studies have been treated unfairly. There’s a taint of imperialism—greedy pharmaceutical companies using poor people of color as guinea pigs.
But with this study, in which all participants were black, it doesn’t seem that way. In a video created by CAPRISA, one of the study participants Gabi Nxele, said she agreed to test the gel because so many people were dropping dead around her, including loved ones. “One of my friends was dying of HIV, but I don’t want to see other people die of HIV,” said Nxele, 28 when the video was made.
Despite the excitement, there is reason for caution. First, the tenofovir microbicide isn’t a magic bullet. Thirty-nine percent effectiveness—or even 50 percent—isn’t the same as 100 percent. Condoms aren't going to disappear. No one knows whether the preparation prevents an HIV positive woman from passing the virus, and it isn’t clear whether it will protect against other STDS, outside of HIV and herpes. And it doesn’t prevent pregnancy.
Cost is also an issue. Activists at the conference in Vienna organized numerous protests—including a die-in that delayed the start of the event. The main concern? The lack of funding for medication for people living with HIV around the world. If drugs like tenofovir are in short supply, how is this seemingly precious resource best used? To save lives of people living with HIV/AIDS or to add it to a gel to prevent more people from getting infected?
It’s also unclear how wide an application this product will have. In the United States among women, African Americans are at highest risk for contracting HIV. One in five Americans aren’t aware of their HIV status, and African Americans are believed to be less likely to know. A woman who has no idea her partner is positive wouldn’t have reason to use the gel.
“I think this will be most useful for married women who feel that they can't use a condom, but might be suspicious and want that bit of protection without demanding condom use,” said Dr. Hilda Hutcherson, a clinical professor of obstetrics and gynecology at Columbia University and author of a number of books, including Pleasure: A Woman's Guide to Getting the Sex You Want, Need and Deserve. “However, I would personally demand the condom if I thought my husband was cheating.”
Dr. Salim Abdool Karim says he’ll also feel more confident once the results are repeated. Another project called the VOICE study is currently looking at 5,000 African women, comparing a gel compound with HIV medication in pill form. Findings are expected in 2013.
“In the scientific community, we need to think about what it is going to take for all of us to work together to make this a reality,” he said. “I would be disappointed if we were not able to make a microbicide tenofovir gel available in three years.”
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