Volume 7, Number 45
30 November 2007

SPECIAL ISSUE: WORLD AIDS DAY

In recognition of World AIDS Day on 1 December, The Pop Reporter is pleased to present this special issue devoted to HIV/AIDS. The issue includes guest commentaries on two important topics in HIV: gender power imbalance and the rampant spread of HIV/AIDS among women, and HIV prevention through family planning and HIV/AIDS integration of services. In addition, we have included abstracts for resources not previously covered in The Pop Reporter, but which represent important research topics for HIV/AIDS. These topics were recently highlighted by HIV expert Dr. John Bartlett in a presentation entitled, "Top 10 Contemporary Issues in HIV." Issues include: earlier start of ART, correlation between most recent CD4 count and death/AIDS, genetic testing, antiretroviral use for HIV prevention, and comparison of ART outcomes in low-resource versus high-resource countries.

Guest Editorials (free with every subscription)

The power imbalance between men and women and its effects on the rampant spread of HIV/AIDS among women

Author: Noman Farooq, Senior Program Associate, Pakistan National AIDS Consortium

noman@pnac.net.pk

While women are battling for equal rights throughout the international community, the existing power imbalance between men and women renders women particularly vulnerable to contracting HIV. As a result, many women cannot exercise their fundamental human right to control their own sexuality. The HIV/AIDS epidemic continues to spread rapidly throughout the world and is disproportionately affecting women.

Although the World Health Organization (WHO) and many governments are implementing educational programs to teach women about protecting their health, traditional cultural practices continue to perpetuate discrimination against women, in turn forcing women into high-risk situations. Unless proactive human rights policies are enacted to empower, educate, and protect women with regard to their sexual autonomy, HIV/AIDS will continue to spread at an alarming rate and will have a devastating impact on all aspects of society.

Vulnerability of Women to Contracting HIV

Abuses of Economic Rights

Economic inequalities between women and men often force women into submissive roles that require them to become economically dependent on men. Some economically dependent women who fear abandonment by their spouses stay in risky relationships in which they lack control over their sexual activity and the ability to protect them from the transmission of HIV. Women who are financially dependent on men are more likely to work in the sex industry, which drastically increases their chances of becoming infected with HIV. Additionally, forced prostitution is prevalent in poorer countries, where women often have no alternative but to exchange their bodies for money.

Abuse of Political Rights

Women are also more vulnerable to HIV infection because of their inability to exercise political rights within their respective cultures. Women are often unable to participate equally in the decision-making processes within their communities. In these circumstances, it is unlikely that policies will be implemented to protect women against the spread of HIV and empower them to control their reproductive health. Women's under representation in political processes translates into unequal access to education and health services because male policy makers often do not prioritize women's needs.

Cultural Beliefs

While progress has been made in terms of women's economic and political rights, some cultural beliefs shape behavior that contributes to the increase of HIV infection among women. One traditional belief is that "good women" are sexually passive and ignorant about sex. Within this cultural paradigm, men are expected to dominate sexual relationships and make reproductive decisions for both partners. While men are encouraged to experiment with their sexuality with partners outside the confines of the marital relationship, women are expected to remain faithful to their husbands. In particular, the practice of polygamy increases men's risk and exposure to contracting HIV, which in turn increases the risk that their female partners will become infected.

Another harmful cultural belief that makes women vulnerable to contracting HIV is the value placed on virginity. In some cultures, people believe that if a man has sex with a virgin woman, he will be cleansed of his infection. Young, virgin girls and women are at a higher risk of being raped by men influenced by this common misperception. These girls and women are especially vulnerable to HIV because of the distinct injuries that result from forced sexual activity and the likelihood that their perpetrators have had multiple sexual partners.

Some cultures place a similar value upon fertility. A woman's ability to become pregnant can elevate her status within her community and help sustain economic survival for herself and her family. Women who link their self-esteem with their ability to become pregnant frequently believe that the use of contraceptives diminishes their fertility. This link between fertility and self-esteem places women in jeopardy of contracting HIV because they sacrifice their own reproductive health to bear children for their husbands. In this respect, researchers in Kigali, Rwanda (Africa) found that when women learned they were HIV-positive, often their concerns focused on their continued ability to have children rather than the effects of the
disease on their personal health.

The Role of the International Community in Protecting Women against the Spread of HIV

The HIV/AIDS pandemic requires a multi-sector approach with short- and long-term relief efforts as well as a focus on changing relations between women and men to eliminate gender inequality and reduce women's risk of infection. In emphasizing the need to eliminate gender inequality, the experts recognized the link between the spread of AIDS and the power imbalance that exists between women and men. The experts recommended long-term plans to control the spread of AIDS, which require that both genders have access to education regarding the prevention and treatment of HIV/AIDS. The experts expressed the need for separate educational programs for men that address men's roles in the prevention and treatment of HIV. Experts also encouraged the implementation of educational programs designed to target school-aged children and teach respect for the social roles of men and women. Experts recommended the use of positive cultural and religious practices to help prevent HIV/AIDS as well as treat and support HIV-infected women. The participants noted the importance of working with community leaders to help identify and address cultural and religious practices that lead to women's disproportionate vulnerability to contracting HIV.

Once the local and international communities understand the implications of these practices, community leaders can help persuade their communities to eliminate some of the negative effects of some of these practices to reduce women's chances of contracting HIV. The effort to involve local communities is difficult, however, in that it addresses cultural relativism. Cultural relativism is a theory that stresses the need to respect the diversity of cultural practices and norms throughout the world to effectuate positive change. Although some criticize cultural relativism because its proponents encourage international bodies to tolerate abusive cultural practices, sensitivity to cultural differences is necessary for the international community to protect women's human rights. The understanding of a particular culture's practices regarding the role of women is essential for the development of effective solutions to reduce the spread of HIV/AIDS among women. Engaging in informed cross-cultural dialogues with local community leaders will encourage other community members to eliminate the harmful effects of certain cultural practices that increase women's chances of contracting HIV. Local solutions might involve the development of health care standards and the establishment of programs designed to alleviate poverty and encourage urban growth, which would help address the economic and political imbalances between men and women.

Applicability of the Convention on the Elimination of All Forms of Discrimination against Women

The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) begins by quoting the Universal Declaration of Human Rights, which "proclaims that all human beings are born free and equal in dignity and rights and that everyone is entitled to all the rights and freedoms set forth therein, without distinction of any kind, including distinction based on sex." Article 1 of CEDAW provides a basic definition of discrimination against women that includes "any distinction, exclusion or restriction made on the basis of sex" that denies a person's full enjoyment of her rights. Although this definition appears to offer women protection from a broad array of discriminatory practices, CEDAW does not specifically list cultural practices or abuses considered discriminatory against women or provide specific guidance for states to protect women from specific harmful cultural
practices.

To the contrary, Article 12 of CEDAW applies directly to protecting women from HIV infection. Article 12 requires states to "take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning." Although AIDS was not originally mentioned in Article 12, in 1990, the Committee on the Elimination of Discrimination against Women issued a general recommendation entitled "Avoidance of Discrimination against Women in National Strategies for the Prevention and Control of AIDS," in which the Committee asked states to report on what they had done to improve women's health and prevent the spread of HIV/AIDS pursuant to Article 12 of CEDAW.

Related Provisions of the International Covenant on Economic, Social and Cultural Rights and the Effort of the Human Rights Committee

The International Covenant on Economic, Social and Cultural Rights provides protection against human rights abuses that increase an individual's risk of exposure to HIV. Article 10 is applicable because it requires the protection of children from economic and social exploitation, which often puts girls at a higher risk of contracting HIV. Further, Article 12 requires states to recognize the right of everyone to enjoy standards of health, including the responsibility to prevent, treat, and control epidemic diseases.

The Human Rights Committee (HRC) issued a general comment entitled "Equality of Rights between Men and Women," in which the HRC strengthened the state's reporting requirements to "provide information regarding the actual role of women in society." In its comment, the HRC identified behaviors and practices that increase women's vulnerability and therefore limit their ability to enjoy equal human rights. The HRC highlighted the reality that subordination of women "throughout the world is deeply embedded in tradition, history, and culture" and prevents women from exercising their rights under the International Covenant on Civil and Political Rights. The HRC's effort is vital because it recognized the relationship between traditional cultural practices that continue to force women into subordinate positions and deny women their basic human rights.

Recommendations

The international community must take an active role in reversing gender inequalities by empowering women to assert their cultural, political, and economic rights without fear of retaliation, violence, or abandonment. Improving women's access to economic resources is imperative. The HRC and the Committee on Economic and Cultural Rights must urge states to comply with their responsibilities to ensure that women have the right to property, the right to work, the right to equal pay for equal work, and the ability to develop business skills. If women can exercise their cultural, economic, and political rights, they will be more likely to become economically independent and less likely to remain in risky relationships.

Women must obtain equal access to health care. Access to health care services such as family planning programs and HIV testing empowers women to make decisions regarding their own reproductive health. Education regarding the methods of prevention and medical services to treat HIV infected women must also become a priority.

The international community must coordinate the education of both men and women regarding the dangerous effects of cultural practices that encourage discrimination against women through local communities. In the long run, these practices will be most effectively addressed through community pressure. Until the international community effectively informs and educates the states regarding their roles in the prevention and reduction of the spread of HIV/AIDS, the epidemic will continue to deny women their human right to life, and in turn will continue to threaten cultural, economic, and political stability throughout the world.

References:

Pakistan National AIDS Consortium
http://www.pnac.net.pk/

AIDS Portal
http://www.aidspnac.org

Family planning and HIV/AIDS integration: An opportunity to increase family planning use AND reduce HIV transmission

Author: Mary Ann Abeyta-Behnke, Senior RH/FP and HIV/AIDS Integration Advisor, USAID

info@hivandsrh.org

Studies documenting family planning use among counseling and testing clients indicate that between 14% and 67% are not using contraception, despite an expressed desire not to become pregnant(1). Rates of unintended pregnancies thus are high, with 51% to 99% of HIV-positive women receiving antiretroviral therapy (ART) in five countries (Uganda, South Africa, Cote d'Ivoire, and Ghana) reporting an unintended pregnancy(2).

This unmet need for family planning has serious implications for both HIV/AIDS prevention and maternal and neonatal health. In addition, HIV/AIDS is associated with an increased risk of adverse pregnancy outcomes for both mother and child. Addressing the unmet need for family planning would alleviate many of these problems, as decades of research on the impact of family planning programs has proven that contraception averts unintended pregnancies and reduces the risk of adverse maternal and neonatal outcomes(3).

Awareness of the pressing need for more widespread FP/HIV integration and linkages has increased in both the HIV and the FP/RH platforms among policymakers and implementers. The "2004 Glion Call to Action on Family Planning and HIV/AIDS in Women and Children"(4) set clear objectives to reduce HIV transmission and unintended pregnancies by calling for services to:

- Prevent primary HIV infection in women,
- Prevent unintended pregnancies in women with HIV,
- Prevent transmission from HIV-infected pregnant women to their infants,
- Provide care, treatment and support for HIV-infected women identified through mother-to-child transmission (MTCT) or Voluntary Counseling and Testing (VCT) programs and their families.

The impact of the "Glion Call" on FP/HIV programming has been substantial. Today, there are increased efforts to ensure FP/HIV linkages capitalize on services already available for MTCT and counseling and testing. Initiatives established to test integration models focus on "no missed good opportunities." USAID partners have stepped-up to provide evidence of successful integration activities by including HIV services in family planning provision, antenatal care, and MTCT programs. The benefits to clients of integrated FP/HIV counseling and services are significant, and studies have demonstrated that such services are a cost-effective approach to reducing HIV transmission.

Due to the increasing availability of HIV treatment and care services, many HIV-positive individuals are accessing the health system through several different gateways. ART facilities are now being tested as a new entry point to reach HIV-positive populations in need of family planning. Other gateways are emerging through care and treatment centers as HIV programs reach out to provide home-based care.

Although these advances are promising, the challenges ahead remain significant. Ensuring well-functioning, high-quality FP/HIV services requires that programs: (1) focus attention on strengthening policies to integrate these programs; (2) maintain contraceptive security; (3) adequately train and supervise personnel; (4) enhance referral networks; and (5) conduct outreach to communities at risk.

A well-coordinated district health delivery system also is critical. District health management teams and the health facility management teams need to organize, plan, and manage the range of health services offered and engage the communities to use these services. In order to provide the complex and comprehensive services that are expected of them, health administrators need skills in all technical areas of health management and administration as well as public relations.

While some country family planning programs are doing well, others require (a) adjustments and strengthening of their FP/RH programming, (b) attention to contraceptive security, (c) policy strengthening, (d) strategic use of population funds, and more importantly, (e) additional funds for population and reproductive health.

With these opportunities and challenges, the U.S. Agency for International Development is undertaking an in-depth FP/HIV assessment in five countries to glean lessons learned. This information and other studies will be presented May 5-6, 2008 at an Integration Technical Working Group meeting with World Health Organization chairing and Ministries of Health participating. Strategic program guidance for country implementation and research will be products of that meeting.

References:

1. Reynolds, H. FHI, 2005
2. Rochat, et al., 2006, Desgrees-du-Lou, et al., 2002; Smart, 2006; Adamchak, et al, 2007
3. Brockelhurst P., French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis. British Journal of Obstetrics and Gynaecology 108(8): 836-848.
4. UNFPA and WHO, 2004
5. Reynolds HW, Steiner, J, Cates Fr. W, Contraception's proved potential to fight HIV. Sex Trans Inf. 2005;81(2):184-5

Note: Information on the Integration Technical Working Group meeting, May 5-6, 2008, will be made available on the Resources for HIV/AIDS and Sexual and Reproductive Health Integration Website at http://www.hivandsrh.org.

HIV/AIDS and STIs RESEARCH

Rate of AIDS diseases or death in HIV-infected antiretroviral therapy-naive individuals with high CD4 cell count
(Abstract; subscription needed for full text; Global)
AIDS. 2007 Aug 20;21(13):1717-21.
The UK Collaborative HIV Cohort (CHIC) Study Steering Committee
Objective: To assess the absolute rate of AIDS and death in antiretroviral therapy (ART)-naive patients with a high CD4 cell count. Such information would be helpful in the design of a trial investigating early initiation of ART.

Design: Analysis of data from an ongoing HIV cohort study.

Methods: The rate of (severe) AIDS or death and death alone was evaluated in ART-naive patients according to the current CD4 cell count, focusing on CD4 cell counts greater than or equal to 350 cells/[mu]l among patients in the UK CHIC Study.

Results: In a total of 30 313 person-years of follow-up, there were 1557 AIDS or death events. The rate of AIDS or death in persons with most recent CD4 cell count 350-499, 500-649 and greater than 650 cells/[mu]l was 2.49, 1.54 and 0.96 per 100 person-years, respectively. The rate ratio for those with CD4 cell count 500-649 cells/[mu]l compared with those with CD4 cell count greater than or equal to 650 cells/[mu]l was 1.55 [95% confidence interval (CI), 1.11-2.17; P = 0.01]. In a Poisson regression model based on person years with CD4 cell count greater than or equal to 350 cells/[mu]l, there was a strong effect of CD4 cell count on rate of AIDS or death (rate ratio, 0.84; 95% CI, 0.76-0.93; P = 0.001), independent of viral load and age.

Conclusions: The trend of decreasing rate of AIDS and death with higher CD4 cell count is present throughout the CD4 cell count greater than or equal to 350 cells/[mu]l range in ART-naive people.

Tenofovir disoproxil fumarate for prevention of HIV infection in women: A phase 2, double-blind, randomized, placebo-controlled trial
(Abstract; subscription needed for full text)
PLoS Clinical Trials. 2007 May;2(5):e27.
Peterson L | Taylor D | Roddy R | Belai G | Phillips P | Nanda K | Grant R | Clarke EE | Doh AS| Ridzon R | Jaffe HS | Cates W
Objectives: The objective of this trial was to investigate the safety and preliminary effectiveness of a daily dose of 300 mg of tenofovir disoproxil fumarate (TDF) versus placebo in preventing HIV infection in women.

Design:This was a phase 2, randomized, double-blind, placebo-controlled trial.

Setting: The study was conducted between June 2004 and March 2006 in Tema, Ghana; Douala, Cameroon; and Ibadan, Nigeria.

Participants: We enrolled 936 HIV-negative women at high risk of HIV infection into this study.

Intervention: Participants were randomized 1:1 to once daily use of 300 mg of TDF or placebo.

Outcome measures: The primary safety endpoints were grade 2 or higher serum creatinine elevations (greater than 2.0 mg/dl) for renal function, grade 3 or 4 aspartate aminotransferase or alanine aminotransferase elevations (greater than 170 U/l) for hepatic function, and grade 3 or 4 phosphorus abnormalities (less than 1.5 mg/dl). The effectiveness endpoint was infection with HIV-1 or HIV-2.

Results: Study participants contributed 428 person-years of laboratory testing to the primary safety analysis. No significant differences emerged between treatment groups in clinical or laboratory safety outcomes. Study participants contributed 476 person-years of HIV testing to the primary effectiveness analysis, during which time eight seroconversions occurred. Two were diagnosed in participants randomized to TDF (0.86 per 100 person-years) and six in participants receiving placebo (2.48 per 100 person-years), yielding a rate ratio of 0.35 (95% confidence interval = 0.03-1.93), which did not achieve statistical significance. Owing to premature closures of the Cameroon and Nigeria study sites, the planned person-years of follow-up and study power could not be achieved.

Conclusion: Daily oral use of TDF in HIV-uninfected women was not associated with increased clinical or laboratory adverse events. Effectiveness could not be conclusively evaluated because of the small number of HIV infections observed during the study.

Outcomes of ART in resource-limited and industrialized countries
(Unpublished Work; Global)
Los Angeles, 14th Conference on Retroviruses and Opportunistic Infections, 2007.
Egger M
Related Unpublished Work: Outcomes of antiretroviral treatment in resource limited and industrialized countries
(You need Adobe Acrobat Reader to access this document)
Background: Since 1996, the introduction of ART has substantially improved the prognosis of HIV-infected patients who have access to these drugs. In recent years, ART has been scaled-up in resource-limited countries in Africa and Asia, where the majority of people with HIV/AIDS live. The WHO estimates that, as of June 2006, an estimated 1.65 million were receiving treatment in low- and middle-income countries, representing around 24% of the estimated 6.8 million people in need of treatment. We wanted to describe the characteristics of patients starting ART in resource-limited and industrialized settings and compare outcomes of ART, including virologic and immunologic response, treatment change, and clinical endpoints.

Methods: Data from treatment programs of adults and children, mainly in Sub-Saharan Africa, which are part of the ART in Lower Income Countries collaboration (ART-LINC) of the International epidemiological Databases to Evaluate AIDS (IeDEA) initiative will be analyzed, including, for example, the Khayelitsha and Gugulethu programs in 2 townships in South Africa, and the Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) program in Kenya.

Results: Results will be compared with data from collaborative studies from North America and Europe, including the ART Cohort Collaboration (ART-CC) and the European Collaborative study.

Conclusions: This presentation describes and compares relevant outcomes of ART in resource-limited and industrialized settings, and discusses pertinent issues, including, for example, the cost of starting treatment late.

PREDICT-1: a novel randomised prospective study to determine the clinical utility of HLA-B*5701 screening to reduce abacavir hypersensitivity in HIV-1 infected subjects (study CNA106030)
(Abstract; subscription needed for full text)
Sydney, Australia, 4th IAS Conference, 22-25 Jul 2007.
Mallal S
Related Abstract; subscription needed for full text: PREDICT-1 (CNA106030): the first powered, prospective trial of pharmacogenetic screening to reduce drug adverse events
Objective: Retrospective analyses have identified several risk factors for abacavir (ABC) HSR, however carriage of the HLA-B*5701 allele is the dominant risk factor. The PREDICT-1 study (clinicaltrials.gov identifier NCT00340080) was designed to provide robust and definitive data on the clinical utility of prospective screening for HLA-B*5701 on the incidence of ABC HSR.

Methods: ABC-naive adults from 314 centres in Europe/Australia were randomised (1:1) to receive an ABC containing regimen according to standard of care [SOC] (retrospective pharmacogenetic screening) or SOC plus prospective pharmacogenetic screening (to exclude HLA-B*5701 carriers). Co-primary endpoints are incidence of (i) clinically suspected ABC HSR and (ii) clinically suspected ABC HSR with immunological confirmation. Immunologically confirmed ABC HSR was determined approximately 6 weeks following initial clinical diagnosis (ABC stopped at initial diagnosis) using epicutaneous patch testing (EPT). EPT results were evaluated by an Independent Committee.

Results: 1956 patients were randomised. Baseline characteristics were similar between the two study arms. The incidence of both clinically diagnosed and immunologically confirmed HSR was significantly lower in the prospective screening arm compared with the control arm; no cases of immunologically confirmed HSR were observed in the prospective screening arm. Conclusion: The results from this landmark study demonstrate that prospective HLA-B*5701 screening results in a dramatic, clinically relevant and statistically significant reduction in abacavir HSR. The PREDICT-1 study provides the high level of evidence required to support the implementation of HLA-B*5701 screening into routine clinical practice and is the first randomised, blinded and powered study to validate pharmacogenetic screening as a clinical tool to personalise therapy.

SPECIAL REPORTS/PROFILES/RESOURCES

Resources for HIV/AIDS and Sexual and Reproductive Health Integration
(Tool; Global)
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Volume 7, Number 4530 November 2007

Guest Editorials (free with every subscription)

HIV/AIDS and STIs RESEARCH

SPECIAL REPORTS/PROFILES/RESOURCES

Volume 7, Number 45
30 November 2007