World AIDS News

Page  1 Daily Conference Newspaper Free of Charge Tuesday, July 21, 1992 SsWORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conf ere nce - -- I -- II IILI ~--- -- Var toH 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 p c c I I f'o t I i11;tr' ii ht:1. replication of effeciive 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-I, 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 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 t-' i ]S zlic i O ii - [,COfDlicr because they are overwhelmed by the endless demands made on them" and warns that entire communities face "destitution and even disintegration" without outside help. The number of women requesting a test for HIV increased after the American basketball player Magic Johnson announced last November that he is HIVpositive, according to a study conducted by the public health department in San Francisco. The "Magic effect", considered potentially responsible for an overall increase of 20% in people seeking HIV testing, lasted for about seven weeks. Increases of more than 50% were seen among Latin and African American women. 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 gpl20 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-rgpl20 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 meg 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 rgpl20 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. I _ Liz Taylor: Scientists unite! Interpretation Interpretation from English into Spanish and French is available at all multidisciplinary and plenary sessions - those that are relevant to all four Tracks. We regret that it was not possible to provide interpretation for Track sessions in Basic Science. Clinical Science and Care. Epidemiology. or Imnpact/Response. 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. This publication of World Aids News is supported by * Bristol-Myers Squibb

Page  2 I WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Tuesday, July 21, 1992 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 HIVtesting 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 HIVpositive 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. Behind bars: many prisons fail to supply condoms. Photo: R. Podernil TASS I- - I- - - - - I I 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 Growth factors help antiviral therapy by Wim Zeijiemaker 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 granulocytemacrophage colony-stimulating factor, recombinant granulocyte colony stimulating factor and recombinant erythropoietin (rGMCSF, 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 ptg/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. Communities must organise to protect themselves, say sex workers. Here, Photo: WHO by H. Anenden a former prostitute in Kenya trains health workers how to convey the message of safe sex. 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 disadvantaged 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."

Page  3 Tuesday, July 21, 1992 WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference I - Activities Announcements Friends for Life Gala Benefit Performances L.C. A *Ir"E Ir... 1 World-famous classical singers and musicians will be performing in a special gala concert on 22 July in aid of the world Aids Prevention Programme. The concert will be staged at the Concertgebouw in Amsterdam. The organisers have planned the concert as a 'musical celebration of life', to coincide with the conference. Artistes including sopranos Roberta Alexander and Elly Ameling, flamenco singer Carmen Linares and the London Festival Orchestra will perform in the show, which will be broadcast live on Dutch and Belgian television. Tickets (f 100) and VIP Cards (f 250) are available from the Concertgebouw box office. The performance commences at 8.15 p.m. Tel: (020) 671 8345. TOr HIUDS undi A programme of classical, jazz, pop and variety entertainment will be staged each afternoon and evening from 20 to 25 July in the centre of Amsterdam, to raise funds for AIDS patients. The concerts, organised by the Fortissimo entertainments agency, will be held at the Beursplein from 12.30 to 23.00 each day, with performances by top Dutch artistes. The funds raised from collections and catering services will go to the Stichting Aids Fonds (Dutch AIDS Fund Foundation). 'Future with AIDS' Dutch church organisations are organising a series of meetings and special services during the conference week, on the theme 'Future with Aids'. An information stand (No. 41) has been set up in the Europahal at the RAI. The Nieuwe Remonstrantse Kerk near the RAI is open daily until Friday, from 3.30 p.m. to 10.30 p.m. A short service will be held at 6.15 p.m., followed by a simple meal, presentations and discussions, in English. On Thursday, 23 July a discussion meeting on Future with AIDS will be held at the Mozes en Aaron Church, Waterlooplein 207. The events are organised jointly by the AIDS working groups of the Netherlands Council of Churches and the Amsterdam Council of Churches, the Mozeshuis adult education centre and the Regenboog centre for drug users. Exhibition Guide The telephone and facsimile numbers for the National Board of Health, Denmark, as given in the Exhibition Guide, are incorrect. The correct numbers are: Tel: +45 33 911601 Fax: +45 33 931 636 Reception The City of Amsterdam is hosting a press reception today at the Muziektheater in Amsterdam. The meeting will be attended by the Mayor of Amsterdam, Ed van Thijn and the Alderman for Health Care, Mrs. Ada Wildekamp. Journalists will travel along Amsterdam's famous canals to the reception, by a free boat service laid on for the event. Departures from the RAI Congress Centre will be between 4.00 p.m. and 5.00 p.m.. The reception begins at 6.00 p.m. KLM Check-in Services KLM Royal Dutch Airlines, the official carrier.for the conference, offers check-in facilities for passengers with hand baggage in the registration area. The desk can also offer assistance with general information and ticketing. Please bring your ticket with you. Opening hours: Tuesday, July 21 to Thursday, July 23: 8.00 a.m. to 6.00 p.m. Friday, July 24: 8.00 a.m. to 2.00 p.m. World Aids News regrets that official announcements only can be accepted for this column. I - - - - - - - - I Programme changes for Tuesday, July 21 to Friday July 24 Changes made after 9.00 a.m. are not reflected here. * Please check TV monitors. Session 56 Marianne Burgard replaced by C Rouzioux Session 57 Ruth Berkelman replaced by Bueher New Session Session 73 Tuesdayv 14:30-16:00. Grote Zaal "Reports from National AIDS CommissionsCo-Chairs: June Osborn, USA/Daniel Tarantola., France Preseniters: David Rodgers. National AIDS Comnmission. USA Ernst Roscamn Abbine. National AIDS Committee. Netherlands Session 74 - Additional Panelist: Helen Schlietinger, USA Session 81 - Anthony iBarniett regrets to cancel New Session Session 84 Tuesday, 16:15 - 17:45, Biauwe Zaal "IDrug Addiction and Human Rights" Chair: Ernest Drucker - USA Panelists: Lester Grinspoon, USA Albrecht Ulmer, Germany Lorenz Bollinger. Germany Francoise Eberhard. France Werner Hermann. Germany Session 88 HIV Clinical Trials: Methods and Ethics Jean Dormont replaced by Jean Pierre Aboulker Session 890 Applying New Diagnostic Methods G. van der Groen - cancelled. Kvc\iit de Cock replaced by K. Bratteggaard. Cote d' Ivoire Tuin Ho Lee replaced hb Yi-Meng Arthur ('hent. lPeople's Republic of China Session 95 Syphilis - Christina Marra P.I.D). - -lunter Hlandesfeld C('hlailmdia - Julius Schachter Gonorrhea -,Ahed Latif Session 0)6 VIRAL VARIATION AND IMMUNITY Chairperson: Susan Zolla-Paziner " #. U SA Session 102 MACROECONOMIC IMPACT OF AIDS Cancelled (held on Monday) Session 103 BARRIERS TO CONDOM ACCEPTANCE Chairperson: Patrick Friel. WORLD HEALTH ORGANIZATION Session 104 Active and Passive Immunotherapy Moderator: Scott Koenig replaced by Emilio Emini Session 105 VIRAL REGULATORY GENES Chairperson: George Pavlakis. United States Session 108 GENETIC VARIATIONS & EPIDEMIOLOGY OF HIV Chairperson: Phyllis Kanki. USA Session III MEASURING AND MODELLING ECONOMIC IMPACT Discussant: Hans Jagecr. The Netherlands Session I I12 AIDS and the Future of Public Health Additional Panelists: Bernard Kouchner, Ministry of Health and Social Services, France Jaime Sepulveda. Secretaria de Salud, Mexico Maria Eugena Fernandez, Health Secretariat, Brazil Zena Stein. New York Psychiatric Institute, USA Session 113 Global Epidemic of Antimicrobial Resistance of STD Pathogens Facilitator: Gavin Hart - cancelled Session 114 HIV DISEASE PROGRESSION, COFACTORS & CLINICAL PRACTICE Indicators of disease progression Victor de Gruttola. Harvard School of Public Health. USA Session 115 HIV/AIDS & DEVELOPMENT ISSUES Interactions between developneint progratms & AIDS programs Sue Lucas. UK NGO Contsortiu0n on AIDS, United Kingdom Session 117 MECHANISMS OF IMMUNOPATHOLOGY Chairperson: Frank Miedema. Netherlands Discussant: Jay Levy. University of California. United States Session 124 Mayors of Cities of the Developing World Impacted by the AIDS Epidemic Panelist: The Honorable Chandrakant Handore (Bombay, India) Session 129 MAJOR OPPORTUNISTIC INFECTIONS Moderator: Jerry Medoff. Washington University Medical School, United States Session 136 Opportunistic Infections Catherine Leport - cancelled Session 137 CLINICAL MANAGEMENT OF PERSONS WITH HIV INFECTION IN DEVELOPING COUNTRIES The Work-Up and Treatment of Diarrhea in a Patient with HIV Infection: MarieMarcelle Deschamps. Haiti Session 139 HIV Clinical Trials Co-Chairman: Praphan Phanuphak, Thailand Key Elements of Master Protocols: Larry Corey replaced by Steven Schnittman, NIH, USA Session 140 Applying New Diagnostic Methods R. Tedder - cancelled P.24 'Antigenemnia Quality Control Assessments for Quantification of HIV Ilnfection' Jaules Bremer. Rush Presbyterian-St. Luke's Medical Center. USA Additional panelist: Prognosis value of HIV (Pg. 24) Antigen in Africans with AIDS: Lukumuena Oscar Kashala. Harvard, USA Session 142 Coordinator: K. O'Reilly, IDS/HRB Additional speaker: Criteria for selecting and prioritsing audiences: M. Horton GPA/IDS Sam Kalibala: cancelled Peter Piot: Cancelled Session 144 HIV/AIDS and the Commercial Sex Industry Diana Allan replaced by Y. Corduff, Sierra, Australia Session 145 ALTERNATIVE, COMPLEMENTARY AND TRADITIONAL THERAPIES Leanna Standish - cancelled Session 152 SOCIOECONOMIC FACTORS AND HIV SPREAD Cancelled Speaker: Donald Acheson,London School of Hygiene and Tropical Medicine, UK Session 156 PATHOGENESIS Chairperson: Frank Miedema. Netherlands Additional Speaker: Hans Wigzell, Karolinska Institute, Sweden Session 160 ROLE OF BREAST FEEDING IN HIV TRANSMISSION Chairperson: Roel Coutinho, Netherlands Session 161 CHANGING MALE HETEROSEXUAL ATTITUDES AND BEHAVIORS Discussant: Kosta Matsoukas. Centre for Conflict Resolution, Australia Session 166 TREATMENT PRIORITIES Availability and accessibility of treatments: Clinical & research issues in developing countries Bernard Liautaud, Haiti Treatment Priorities for Women Patricia Kloser, New Jersey Medical School, United States Session 167 REVERSE TRANSCRIPTION & INTEGRATION Discussant: William Haseltine, USA Session 174 Approaches to AIDS Activism Petra Narimani replaced by Werner Hermann, JES, Germany Session 176 The Hemophilia Community: Responses & Challenges Health care staff issues: Rosemary Daly, Ireland Session 178 EPITOPES OF T-CELL IMMUNITY Chairperson: Gene Shearer, United States Session 184 PERSPECTIVE OF RELIGIONS Moderator: Robert J. Vittilo. Caritas Internationalis, Vatican City Session 185 Women's Access to Prevention and Care Additional Panelists: Nkatdu Luo, University Teaching Hospital of Lusaka. Zambia Patricia Kloser, New Jersey Medical School, United States Ileana Rivera, Health Force: Women Against AIDS, United States Session 188 All-Party Parliamentary Group on AIDS Tuesday, 21 July, Wellcome Hospitality Room Please contact Alisa Butler, Tel: +44 71 2196928 Session 190 Clinical Trials Interim Data: Jan Tijssen, the Netherlands Session 192 EPIDEMIOLOGIC METHODS FOR SURVEILLANCE AND PREDICTION Projections and Policy Makers: Donald Acheson - cancelled Session 193 Day 3. Mini Course 7, POLICY PLANNING AND EVALUATION OF INTERVENTION Coordinator: E. van Praag, Chief IDS/HCS 'Service-based approaches': E. van Praag 'Case example: Counselling and testing': S. Kalibala/Uganda 'Early diagnosis and treatment of STD': P.Piot/Belgium 'Monitoring and evaluation': K. O'Reilly, GPA/IDS. D. Wilson, T. Mertens, GPA/EVA 'Political commitment for intervention work': P. Lamptey/USA Discussion 'Summary and the way ahead': M. Merson. Director. GPA Session 221 RISK BEHAVIORS AMONG DRUG USERS Discussant: Graham Hart, Middlesex School of Medicine, United Kingdom Session 196 Alternative, Complementary and Traditional Therapies Additional Panelist: Howard Moffet, USA Session 242 LAB DIAGNOSIS OF CHLYAMYDIA AND GONOCOCCAL INFECTIONS Discussant: Ramon Soriano, Spain Session 259 EPIDEMIOLOGY OF HTLVs Discussant: Yi-Ming Arthur Chen, Institute of BioMedical Sciences, Academia Sinica, Taiwan Poster announcements Poster PoD 4648, "HIV risk acts of gay male youths: The mediating role of stress" can be found on poster board PoC 4648 in the Europahall The abstract of B. Wyendaele. TuC 0540, "Effect of counselling on STD incidence in STD patients in Malawi" can be found in poster format in block E6 The abstract of Francisco Ramos, "Accidental injuries among dental healthcare workers" can be found on Poster PoC 4366 in the Ainstelhal Closing Session Messages of I-lope anl Life Additional panelist: Maryn de Koning, The Netherlands Satellite sessions All-Party Parlimentary Group on AIDS Tuesday, 21 July Wellcome Hospitality Room Contact: Alisa Butler Tel: +44 71 2196928 International Symposium on and HIV/AIDS 1 1.00 a.m., Wednesday. July 22 Nutrition Novotel Europa Boulevard 10 Amsterdam International Symposium on the Management of HIV Disease 7.30 a.m. Saturday. July 25 Novotel Europa Boulevard 10 Amsterdam

Page  4 5 A m WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Tuesday, July 21, 1992 Tuesday, July 21, 1992 WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Drug legalization: A matter of public health and human rights e rise 0 t t ic 0 'accine 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? 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 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 grains. *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 WORLD AIDS NEWS Conference Newspaper VIllI international ( cntcrecc on11 AI)S/ Ill STD Woarld (Congress Amsterdam. Thc Nethcrlanmd 19-24 Ju1 1992 Editor: Shartn Kingman D)eputy Editor: Cind\ Pattont Writers: William Check Janis Kell Simon Reo/cndaal Wirn Zcijlc1inaI. c Translators: luia I iansclaar Annctte Etkcna/i Managing Editor: Jackic ailes Production Manager: Karin Baistcr La'out & Design: Kuipcr & (Comrpan. Photography: Robh lst F tom raie j13 V AIDS epidemic: early identification 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 dislocation. 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 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 eive a vaccine that will mitigate or delay the course of the disease? It is too ealrly to say how successful that is oinge to be, but there are somei 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 gpl60, 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 tr pr+ +. <:+; Vaccie resLarch is there A cuckL o. in the nest!',+avz:,,ffJ 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 lifethreatening 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.fture of a country and the filture 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, prio.iessor 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 themn 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 successfuld as measles and mumips, 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, lie agrees, that so much money may be sunk into developing a therapeutic vaccine that there will be less lefi over for work on a prophylactic vaccine. But at least the "carrot " of the market for ca therapeutic vaccine may keep some biotechnology companies in the field for longer than if the' were only looking at the market for a prophylactic 'vaccinme, he saYs. 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 highrisk 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 youi could elt a hiohlogical cllect ill individuals who are infected, it would spur on I efforts to get a prophylactic vaccine." But can we assume that sonmething 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;ahwyler therapeutic benefit, I am not sure that, on its own. makes it a lead candidate for a prophylactic vaccine. ints", in If you are infected, you already have on the a vigorous response to HIV. So a 50 microgramn dose could be efficacious as a therapeutic vaccine, but it could -rcn take perhaps 50 times more to t wi achieve a prophylactic vaccine." 'Chalk and cheese' Jonathan Weber. professor of commnunicable discase at St Mary's Hospital Medical School in London. says classical ilnmunology suggests ie British that the mechanisins by which a 's AIDS viral infection is prevented are quite London, different fromn the ones that control )I people it. Neultralising antibodies are crucial ns. Let's for protection. Prophyl actic rkers of vaccines, mostly derived from viral h people enyvelope subunits, ailn to stilnulate d quality such antibodies, but. Weber says, it introlled is hard to see a role for neutralising d clinical antibodies once someone is infected. B3y contrast, cellular immunity is tech, the needed to control infection once it company has taken place. "'You are comnparing rapeutic chalk and cheese." mmna: "If He says he has seen no data at all so hints \you far that suggests that therapeutic s for the illnmunisation is effective. "For me. the trial it remains wishful thinking - wishful alth care thinking that I nevertheless strongly. If tile support. " Even if a therapeutic vaccine does eventually become available, will it reach people with Photo: Carl G AIDS such as this 18-year-old in Central Africa, here being comforted by his parents Published by: iublisher: Printing: Mledialert Projckten BV Willemn Krteling Sallkind Rotatie I)rukkecrij, Dcenlter Conference Directors of (nomnmunications: Iilars Rao None LTI lldheerL' 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 rgpl60 - 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 rgpl20 in the laboratory and. when shown cells with gpl60 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 socalled "surrogate" or "laboratory endpoint" - there will be cnorlmous pressure to make such preparations available without waiting for the results of large trials such as that planned by Valentine. This would measure "clinical endpoi other words, the effect patients' state of health. Geoffrey Schild, head of th Medical Research Council Directed Programme in says: "There is a danger o coming to hasty conclusio not confuse surrogate mai benefit like virus load wit surviving longer with gooc of life. We need well-co long-term studies with good endpoints." Phillip Berman. of Genen Californian biotechnology c which is also testing the vaccines. sums up the dile you go for clinical endpc will have to wait for vear; results. particularly if subjects get the kind of he that you get in the IUS Conference (Communications staff: JoIhn \'illoghbCC Picn Wittesceni Supported by an educational grant from,ý Bristol-Myers Squibb The opiTiions CexpresCWd are tihoise,lelI fl tieC authiors. Thec (onillcreicc Nc\sspapcr glatellull ackn lcedges Lthe' eter'i iiit is t a..CIl ICCie Van feck Automiaiserini.

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Page  6 WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Tuesday, July 21, 1992 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. 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%. 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%c. 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%C. "This is indirect proof that if you priomote 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. Judith Wasserheit: A dangerous synergy Firm evidence is accumulating about the connection between HIV infection and other STDs, and it's not good news. According to Dr Judith Wasserheit, director of the division of STD/HIV prevention in the National Center for Prevention Services at the Centers for Disease Control in Atlanta, Georgia, "We now have fairly substantial evidence that most of the STDs, both genital ulcer diseases (GUDs) and nonulcerative STDs - discharge syndromes like gonorrhoea and trichomonas - facilitate HIV transmission." Data so far are more substantial for the GUDs (chancroid, herpes, syphilis and the like) Dr Wasserheit says, but there appears to be at least a three-to five-fold increased risk of HIV transmission associated with all STDs. If evidence linking nonulcerative STDs with HIV transmission is confirmed, the overall impact of the discharge syndromes on HIV transmission will be much greater than that of the GUDs, because STDs that do not involve ulceration are much more common, says Wasserheit. Recently the picture has become even more ominous. HIV seems to prolong the period of infectiousness and spread of other STDs, either by making them more infectious or by making it harder to cure them. STDs, in turn, seem to facilitate HIV transmission. If these trends hold true, says Wasserheit, "We are seeing an unusual epidemiological synergy, a mutually reinforcing spiral. In fact, in some parts of the world, particularly in Africa, that synergy may underlie the explosive growth of the HIV epidemic." What does this mean for efforts to curtail the spread of HIV? Smear test for gonorrhoea Photo: WHO/ T. Farkas 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, epidemiologists) 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.

Page  7 Tuesday, July 21, 1992... -- " WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Public health at the crossroads How epidemiology raises awareness of AIDS by Simon Rozendaal In 1984, Dr. Praphan Phanuphak saw a sick American who was referred to his laboratory in Bangkok, Thailand. From what he had read, Praphan suspected that this would be his country's first AIDS patient. He was right. The American had pneumonia and in February 1985 was diagnosed with AIDS. The epidemic in Thailand, as in many other Asian countries, began late. The first recognized cases were in homosexuals: this American and a retrospectively identified Thai graduate student who returned from the US in mid1984. Today, the AIDS epidemic in Thailand is largely among heterosexuals. Of the 400,000 Thais thought to be infected with HIV, the majority are heterosexual and equally distributed among women and men. Officially, the number of AIDS patients in Thailand is 500, but,. says Praphan, "the number is probably two or three times as high." AIDS cases double Praphan, a 47-year-old professor of medicine and immunology and the director of the Thai Red Cross Programme on AIDS, agrees with epidemiologists who fear that the epidemic in Asia will reach the same proportions as in Africa. India and Thailand have already witnessed the number of cases doubling at the same rate. According to Praphan, one of Thailand's problems is that the many young male Thais have their first sexual experience with a prostitute. "That is different from, for instance, the US, where boys of 15 or 17 have their first sex with girlfriends from next door or from school." Praphan believes that Thailand followed anything but the ostrichapproach in its approach to AIDS and sexuality. Several ministries joined forces in the project "100% condom usage", an information campaign directed primarily towards prostitutes and massage parlour workers, but also at other workers in the sex industry, police officers, owners of massage parlours and customers. Teams equipped with videotapes went to prostitutes and showed them how to convince a customer that he should use a condom. Sex education Sex education for young people has also turned out to be a necessity. "Fifty percent of the Thais leave the school system after primary school so you have to reach them there." says Praphan. "In the past there existed at some schools what we called family health education., But today it is very directly geared to sex, AIDS, STDs and contraception." Data from epidemiological surveys proved essential to increasing awareness about AIDS in Thailand. Every province tested the blood of at least ten and often hundreds of people in categories such as pregnant women, blood donors, patients with sexually transmitted diseases (STDs), military personnel and so on. The survey was conducted over three and a half years and showed that hundreds of thousands must be infected. Responsibility Praphan believes that this kind of survey helps increase awareness about AIDS. "The survey made us address the problem openly," Praphan says. "I think that if other Asian countries were to do the same kind of surveys, there would be more awareness of the importance of AIDS in Asia." Praphan believes Asian researchers and clinicians can take a more prominent role in the AIDS crisis. "There is uncertainty about the role of the WHO," says Praphan. "Thai authorities think that the WHO will do the job. But we should take the responsibility ourselves, otherwise it takes too long." Dr Anne Petitgirard is aiming to make Red Cross/ Red Crescent societies more effective lobbyers Photo: Rob List by Janis Kelly A firm foothold in the community and a strong commitment to human rights are the keys to the AIDSrelated work of the Red Cross/Red Crescent Societies, but something more is needed, says Dr Anne Petitgirard, AIDS Coordinator for the International Federation of the Red Cross/Red Crescent Societies. "Maybe I am naive, but I feel that we are really at a crossroads. We need to invent something new in public health, something closer to the needs of the people." Her office helps to establish the overall direction of the Red Cross/Red Crescent AIDS strategies - an example is the stand against workplace discrimination - and provides resource material for the individual societies to use in their AIDS-related programmes. Strategy The growing involvement of the Red Cross/Red Crescent societies in the broader issues of the AIDS pandemic was highlighted by a 1991 resolution reaffirming the societies' commitment to the fight against AIDS and expanding their strategy to include plans for more educational programs, more care and counselling of people who have HIV. and more opposition to discriminatory legislation. In particular, the Red Cross/Red Crescent societies have objected vigorously to plans to hold any international or major regional AIDS meetings in countries with discriminatory government policies, including the US and Japan, which is the proposed venue for the 1994 international conference on AIDS. Basic principles Petitgirard says: "Although the Red Cross/Red Crescent societies are identified with blood collection in many countries, we are actually involved in a much wider range of health activities. As in many of these areas, the fight against AIDS brings us back to one of our own basic principles, which is the defence of fundamental human rights. If we don't solve that problem, we will not be able to solve the major health problems facing the world at this time, including AIDS." She says she was amazed at the unprecedented number of questions and suggestions from Red Cross/Red Crescent offices in the field on what topics should be covered at the Red Cross/Red Crescent AIDS Seminar being held in conjunction with this week's international conference. "I am greatly encouraged by this evidence of growing involvement with AIDS prevention and control. At times I have experienced, as nearly everyone does, the feeling of being overwhelmed by the job to be done, but I am now more and more convinced that we can make a difference. "I have come around again to thinking that community-based organisations such as the Red Cross/Red Crescent societies are particularly important because they are often closer to the people and can play a role as intermediaries between the community and government policy-makers. We need a type of solidarity which is more than just working together. We need to reinvent our common goal. We need to go back to the community and ask, What is really needed? Where should we put our resources?" Unpopular positions Petitgirard tries to help the individual Red Cross/Red Crescent societies feel free enough and secure enough to advocate for unpopular positions in the face of government opposition. This can be very effective, as when steadfast Red Cross/Red Crescent opposition contributed to the demise of discriminatory proposals on visa requirements in Thailand. "It is often difficult to get the ear of the government. One of my goals is to find ways to help Red Cross/Red Crescent societies be more effective at this kind of lobbying," she says.

Page  8 5571095.0052.009 WORLD AIDS NEWS The Newspaper of the Harvard-Amsterdam Conference Tuesday, July 21, 1992 Le Sida en prison Les prisonniers ne peuvent pas se proic cer correctement contre le virus HIV et le Sida. Dans la plupart des pays. les autiorits pdnitentiaires ne procurent pus de prdservatifs parce clue les rapports sexuels entre prisonniers sont interdits. Pour la meme raison., ils ne disposent ni de seringues propres. ni d'eau dcjavel pour les nettoyer. En outre., de nombreuses prisons effectuent des tests HIV obligatoires et certains etablissements isolent les seropositifs. Ainsi., la plupart des prisons n'observent pas les rigles de 1987 de l'OMS, comme i'a decla re l'un A Dure repress prost En Thaflande, les prostitudes 6trangbres entr6es clandestinement risquent la de6portation et parfois mrme la peine de mort, selon un groupe d'action de prostitudes en Thailande. Chantaiwipa Apisukh, de EMPOWER (I'Education Est la Protection des Femmes Employees i la Prostitution), a d6clard que cette ann6e dtjA prbs de 20 femmes ont 6t6 d6port6es en Birmanie et que, le r6sultat du test HIV s'6tant r6v6l6 positif, une injection mortelle leur a 6td administr6e i leur arriv6e. Du fait de la faillite &conomique de l'Inde, les familles des classes movyennes n'arrivent pas a joindre les deux bouts et les mores ont recours i la prostitution i domicile i ti des orateurs americains lors d'une des sessions consacree lundi auI "Sexe et les drogucs en prison".Le virus HIV ct le Sida constituent un enorme problme dans les prisons. surtout dans des pays tels que I'Espagne et lItalie oi la plupart des toxicomanes sont seropositifs. Dans les prisons madrilenes, la frequence de la siropositivite atteint 55 %. Aux Etats-Unis, pres de 7000 prisonniers ont le Sida. A New-York. l'6pid6mie de tuberculose corollaire du HIV constitue un problime particulier. on contre les tudes cinq A six fois par mois, selon Swaminathan Sundararaman, de la Fondation de la Recherche sur le Sida en Inde, a Madras. Une 6tude de Diana Alan, conseillbre d'un projet du gouvernement australien pour l'analyse des besoins des transexuels, montre que 80% d'entre eux s'y prostituent. Les transexuels ne peuvent en appeler i aucune loi anti-discriminatoire et ne participent i aucune des strat6gies priventives existantes: ils ne sont considerds ni comme des femmes ni comme des homosexuels et sont oubli6s dans la plupart des projets concernant Ia prostitution, selon Alan. Amrnfar, la Fondation americaine pour la Recherche sur le Sida va donner pris de 300.000 dollars A la lutte contre le Sida en Argentine. Elisabeth Taylor, presidente fondatrice de Amfar a annonc6 hier, lors d'une conference de presse, que l'argent serait r6parti entre six projets de prdvention destines a la communaut6 homosexuelle, aux toxicomanes, aux jeunes femmes, aux siropositifs et i leurs families. Liz Taylor a r6affirm6 son engagement dans la lutte contre le Sida et d6clar6: "Je suis lasse et afflig6e. Lasse d'avoir i convaincre le monde, encore et toujours, que le Sida est une menace universelle pour l'humanit6 entibre." Elle a lanc6 un appel aux scientifiques: "Nous sommes tous des compagnons de voyage en route vers la d6faite du Sida. Depuis la table de laboratoire au lit du malade, du grand nord au pile Sud, nous appartenons tous i Ia communaut6 mondiale qui veut endiguer le Sida Inaintenant." Liz Taylor a exhorte les femmes a prendre tris au sdrieux les risques de contamination du HIV. "La contamination peut tre vaginale, elle n'a pas toujours lieu par sodomie", a-t-elle dit. Les facteurs de croissance Les dernieres etudes montrent que les facteurs de recombination de croissance hemopolftine peuvent avoir un effet bindfique dans le traitement duI Sida. Les m6dicaments antiviraux tels que le ganciclovir et la zidovudine provoquent souvent une an6mie telle que le traitement doit 8tre interrompu jusqu'A ce que la numdration globulaire du malade se soit retablie. Cependant, le traitement par les facteurs de croissance semble diminuer la L'epidemie a long terme n6cessit6 d'interrompre le traitement et ameliorer la qualit6 de la vie du malade qui a plus d'6nergie. Les facteurs de croissance utilis6s dans les etudes sont le facteur recombinant macrophage-granulocyte stimulateur de colonie, le facteur recombinant granulocyte stimulateur de colonie et le facteur recombinant 6rythropoYi6tique. Le seul effet d6tfavorable fut une douleur osseuse constat6e chez une minorit6 de patients. Hier, lors d'une session pldniere, les scientifiques ont d6clar6 que les comportements humains et sociaux doivent changer plus rapidement car le virus HIV evolue et I'6pid6mie se propage dans Ic monde entier. Gerald Meyer a d6clar6 que les modifications g6n&tiques du virus HIV se poursuivent. II y a maintenant 5 sous-types principaux de ce virus, mais on n'a pas encore identifid de malade doublement contamind par deux sous-types du virus. Cela pourrait signifier que la contamination par I'un des sousvirus bloque l'entrde A un second sous-type. Dans ce cas, il pourrait etre possible d'utiliser un sous-type non mortel comme protection contre l'infection des virus mortels. Le dr. Anke Ehrhardt a ddclar6 que les projets de prevention contre le Sida ne sont efficaces que s'ils sont congus par les membres des communaut6s auxquelles its s'adressent. Elle a ajout6 que les positions moralisantes des groupes religieux de nombreux pays empechent les fonctionnaires de Ila santt publique de developper I'information n6cessaire a la creation de programmes educatifs r6alistes. Le dr. V. Chandra Mouli a d6clard que de nombreuses 6tudes prouvent actnuellement que les programmes de pr6vention bien congus sont efficaces. Mouli a ajoutW qu'il y a un besoin aigu de tels programmes dans les pays en voie de d6veloppement, car le fardeau des soins aux malades du Sida et aux orphelins du Sida pbse lourdement sur les riseaux familiaux 6tendus, qui finissent par tomber en lambeaux. I IL~ -IC, ~I ' -II I ~I~, I, I I El sida en la carcel Los presos no son capaces protegerse ellos mismos contra el VIH y el sida. En la mayoria de los paises las autoridades penitenciarias no entregan preservativos porque contactos sexuales entre los reclusos no estin permitidos. Jeringuillas limpias y agua de javelle para limpiar las jeringas para inyectar la droga, no son repartidas por las mismas razones. SY encima en muchas carceles es oblioatorio someterse a un test VIH y en algunas los seropositivos son puestos en aislamiento. Asi la mayor parte de las etirceles no actuan de acuerdo con el reglamento del 1987 de la Organizaci6n Mundial de la Salud (OMS), un orador americano decia ayer en la sesi6n 'sex y la droga en prisi6n'.El sida y el VIH son in problema muy grave en la carcel, sobre todo en paises como Espafia e Italia donde una gran parte de los drogadictos es infectado por el VIH. En las cairceles de Madrid el 55% de la poblaci6n reclusa es seropositivo. En los Estados Unidos casi siete mil encarcelados tienen el sida. Un problema especial en Nueva York es la epidemia de tuberculosis relacionado con el VIH. Duras penas para prostitutas En Tailandia, cuando una mujer extranjera que ademas entr6 en el pais ilegalmente, trabaja en la prostituci6n se puede encontrar con la pena de ser deportada y hasta matada, segun datos de un grupo de ayuda a las prostitutas en Tailandia. Chantaiwipa Apisukh de EMPOWER (Educaci6n significa protecci6n para las mujeres que trabajan en prostituci6n). dice que hace unos meses el gobierno de Birma mat6 mediante una inyecci6n mortal a unas 20 mujeres que fueron deportadas a este pais y que resultaron seropositivas por el VIH. La mala situaci6n economica en India obliga a las familias de clase media y que no pueden pagar las facturas mensuales, a recurrir a la prostituci6n en casa cinco o seis veces por mes, segiin Swaminathan Sundararaman, de la Fundaci6n para la Investigaci6n del Sida de India en Madras. Un estudio por Diana Alan, consejera del proyecto del gobierno australiano para analizar las necesidades de los transsexuales, demuestra que un 80 por ciento de los transsexuales en Australia trabajan en la prostitui6n. Los transsexuales no pueden recurrir a una ley antidiscriminatoria ni reciben apoyo en medidas de prevenci6n porque no se les considera ni mujer ni homosexual. Y por lo tanto son los olvidados en casi todos los proyectos de ayuda a las prostitutas. dice Alan..E Taylor, Amfar, la Fundaci6n Americana para la Investigaci6n del Sida, va a dar casi trescientos mil d61ares para la lucha contra el sida en Ar entina. Elizabeth Taylor, uno de los fundadores de Amfar, anunci6 ayer en una conferencia de prensa que el dinero se debe dividir entre scis proyectos sobre prcvenci6n para Ia comunidad homosexual, drogadictos, mujeres j6venes y personas seropositivas y sus familias. Taylor reafirm6 su interts por la lucha contra el sida. Decia:"Estoy cansada y triste.Cansada de tener que repetir continuamente a todo el mundo que el sida es una amenaza a la humanidad". Hizo Lun Ilamamiento a los cientificos:" Aqui y siempre somo compafieros de viaje en el camino para combatirc el sida. Desde los laboratorios a la cama. desde el polo norte al polo sur. todos somos parte de la comunidad universal que quiere parar el sida lo antes posible."La Taylor avis6 a las mujeres del serio riesgo del VIH. "Se puede ser infectada por la vagina. no solamente por el coito anal". dijo.Finalmente, cada individuo decideri sobre el riesgo que quiere tomar." La epidemia a largo plazo Factores de crecimiento La conducta humana y social debe cambiar mas ripidamente porque el virus evoluciona y la epidemia se propaga por el mundo, decian cientificos ayer en una sesi6n plenaria. El VIH esti sometido a cambios geniticos, decia Gerald Myers. Existen ahora cinco subtipos del virus, pero ningun enfermo que hasta ahora ha sido identificado tiene una infecci6n doble con dos subtipos del virus. Esto puede significar que el estar infectado por un subtipo no permite la entrada de un segundo subtipo. Si fuera lo contrario, pueda ser posible utilizar un subtipo alterado, no mortal para proteger el enfermo contra una infecci6n del virus mortal. Dr. Anke Ehrhardt decia que los programas de prevenci6n para el sida, solo tienen sentido cuando las comunidades para quienes estos estdn elaborados, forman parte en la preparaci6n del programa. Dijo que ]a actitud 'moralizante' de algunos grupos religiosos en muchos paises impiden que las autoridades gubernamentales sanitarias establezcan unos proyectos de educaci6n realistas. Dr. V. Chandra Mouli ha dicho que existen pruebas que los programas de prevenci6n que estdn a la altura de la situaci6n, son muy eficaces. Mouli declar6 que la necesidad de este tipo de programas es muy urgente en paises en desarrollo. Sobre todo en estos paises el cuidado de los enfermos del sida y los hu6rfanos a causa del sida, pesa mucho sobre los hombros de los familiares y a veces produce la desintegraci6n de la familia. Los estudios mas recientes demuestran que el recombinante hemopoyetina con factores de crecimiento puede ayudar en el tratamiento para el sida. Medicamentos antiretrovirales como ganciclovir y zidovudine muchas veces causan anemia y como consecuencia se debe interrumpir la terapia hasta el enfermo haya recuperado el recuento sanguineo. Pero el tratamiento con los factores de crecimiento tanto parece reducir la necesidad de interrumpir la terapia como mejorar la calidad de vida para el enfermo debido a una mayor energia. Los factores de crecimiento usados en la investigaci6n eran el recombinante granulocitomacr6 -fago colonia-factor estimulante, el factor recoribinante granulocito colonia-estimulante y el recombinante eritropoyetina. Solo una minoria de enfermos sufrian dolores esquel6ticos con este medicamento.