The argument for special ARV programmes for health workers and teachers
The HIV/AIDS epidemic in the developing world has adversely affected education and the health sector, with a high prevalence of HIV among teachers and health workers. In Zimbabwe, for example, it is estimated that by the end of 2003, 30% of all teachers were HIV positive. In the absence of treatment, AIDS will massively affect the supply of teachers, lowering the teacher-to-student ratio even further along with quality of education. In one Harare hospital, the number of staff deaths increased from 75 in 1993 to 250 in 2000, and a health research institute with 120 staff lost 15 members to AIDS between 1992 and 2002. Almost half of the deaths were among scientists and senior laboratory technicians, but the worsening nurse-to-patient ratio is also having an impact on quality of care.
This loss of key experienced professionals puts an increased burden on those who are left, both in terms of the threat from HIV/AIDS and in their ability to deliver services. Provision of antiretroviral drugs to teachers and health workers therefore becomes more than just an ethical consideration. Health workers are involved in the day-to-day management of patients, including care and support of people with HIV/AIDS, while teachers educate and support children and orphans in their institutions. Unless existing programmes also address the needs of these professionals there is a danger they will lose interest and motivation. However, when the Botswana government began providing antiretroviral drugs, many health workers, despite their level of knowledge, failed to access the drugs because of problems such as reluctance to test for HIV, stigma and uncertainty about confidentiality. Developing countries can ill afford to neglect these critical issues and should provide treatment for their skilled workers as part of the fight against the epidemic.[1]
Health Development Networks Key Correspondents Team. Keeping health and education sectors alive–do we need special ARV programmes for health workers and teachers? AIDS 2004 report. 3 August 2004. At: 〈http://www.procaare.org〉.
Canada allows African countries to buy antiretrovirals duty-free
Legislation passed in the Canadian House of Commons in November 2003 amending the country's patent laws allows drug makers to manufacture and export generic versions of patented drugs to developing countries. This enables them to provide inexpensive ARVs and other medicines to about 50 eligible countries at a fraction of the prices charged in Canada. So far Kenya has taken advantage of this offer and Uganda is being encouraged to follow suit. 1 The US, on the other hand, appears to be pressuring developing countries to give up their recently hard-won right to produce cheap, generic anti-AIDS drugs by bribing them with favourable trade deals. In particular, Thailand's thriving generic drug industry could be at risk as they negotiate a trade agreement with the US. 2
Ahimbisibwe F. Canada to give duty-free ARVs. The New Vision, Uganda. 4 August 2004.
Fleck F. Bush accused of pressuring countries to stop producing generic drugs. BMJ 2004;329(7459):192.
US policies hinder AIDS initiatives from all directions
The US AIDS plan announced in January 2003 is distributing $15bn to fight AIDS over the next five years. However, according to a study by the Centre for Health and Gender Equity, operational strategies in most of the recipient countries are using faith-based NGOs rather than public health channels, and circumventing local community groups that are experienced in AIDS work. These new schemes put excessive importance on abstinence, hampering the promotion of condoms and discriminating against groups that provide information on safe abortion. The report also cites incidences of successful projects, funded for many years, suddenly having funding withdrawn because they have contested the new plans. These claims are denied by the chief architects of the plan and all the criticism is dismissed, but the evidence suggests that US officials are on the defensive. 1
Walgate R. Bush's AIDS plan criticised for emphasising abstinence and forbidding condoms. BMJ 2004;329(7459):192.
Dual malaria and HIV infection increases risk to mother and baby in Zimbabwe
This study of 986 pregnant women in Zimbabwe investigated the effects of infection with malaria and HIV on pregnant women and neonatal outcomes. The prevalence of HIV and symptomatic malaria in the women was 8.3% and 14.7%, respectively. HIV-positive women were more likely to develop malaria attacks during pregnancy than seronegative women. Malaria infection was also associated with increased risk of stillbirth and HIV infection with pre-term delivery. Both infections were independently associated with increased risk of low birthweight, very low birthweight, low Apgar score and fetal growth retardation. Dual infection with malaria and HIV was also associated with increased risk of maternal, perinatal and early infant death. The conclusion is that women with either HIV or malaria infection have a significantly increased risk of adverse outcomes of pregnancy and childbirth, while dual infection has even greater detrimental effects on both maternal and infant survival. 1
Ticconi C, Mapfumo M, Dorrucci M, et al. Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe. Journal of Acquired Immune Deficiency Syndromes 2003;34(3):289–94.
Microbicides 2004, London, 28–31 March 2004: an overview of the issues
Topical microbicides are vaginally or rectally administered agents designed to block HIV attachment to or insertion in susceptible target cells, and research to find a safe and effective microbicide has been going on for about a decade already. Several issues dominated this scientific conference: the basic science of the mechanisms of sexual transmission of HIV, standards of care in microbicides research and trials, and strategies for studying how trial microbicides behave in the vagina when exposed to HIV (in animal models).Clearly, technical development has progressed a great deal since the first microbicides conference.[1] Prospects for the development of usable microbicides are improving.
Other abstracts and presentations covered such topics as safety and acceptability of different microbicidal formulations, acceptability of different applicators, affordable rapid HIV testing, monitoring of people with AIDS on antiretroviral treatment in low-resource settings, use of an intravaginal ring for long-term controlled delivery of microbicides, extent of irritation of vaginal and penile tissue of different microbicidal formulations, developing a clinical trial protocol for a multicentre study, and the importance of the anti-STI efficacy of different microbicides for different STIs in different settings.
However, perhaps the most important question participants confronted was which methods under development to concentrate on. Of the 40 or more microbicide gels and creams currently being developed, six are about to go into large-scale phase III trials. Five of these belong to the same class of compound, sulphonated polyanions, with the same mechanism of action, interference with HIV attachment to susceptible immune cells. One of these products also lowers pH in the vagina to levels which may damage or kill viruses. Many believe there is limited value in testing so many almost-identical products in separate large-scale clinical trials. This situation has come about because of separate sponsors working on separate products, which has discouraged cross-product comparisons. They argue that it makes better sense to assess these products from the available phase I and II data and only put the best one into a large-scale trial. If multiple products must be tested, because no one is prepared to withdraw “their” product, it would make sense to test them together in a single randomised trial to reduce bias and confounding factors. There is also concern that this group of microbicides have all been developed using laboratory-adapted strains of HIV which differ in key surface molecules from sexually transmitted strains. 2
Second generation microbicides with improved activity are currently in phase I or II trials and they too will need to be tested in the near future. A pile-up of phase III trials can only delay progress in the long run. Delaying the implementation of large-scale phase III trials of first generation methods will delay progress by one or two years. However, the risks and costs of such a pause must be compared with the risks and costs of proceeding. Difficult decisions must now be made. 2
Microbicides 2004. Conference abstracts. 28–31 March 2004, Hilton London Metropole. At: 〈www.microbicides2004.org.uk〉.
Gross M. HIV topical microbicides: steer the ship or run aground. American Journal of Public Health 2004;94(7):1085–89.
US assisted conception clinic refuses to risk HIV transmission to surrogate mother
A US assisted conception clinic recently refused to help a homosexual male couple, both of whom were HIV-positive, by fertilising an ovum from a woman donor with the sperm of one of the two men and implanting it in a second woman who had agreed to carry the pregnancy. The men contested the decision on the grounds that there were no documented cases of HIV seroconversion in recipients of gametes from HIV-positive donors, and that the woman was willing to carry the pregnancy. However, although the clinic offers assisted conception for both HIV-discordant heterosexual couples and for same-sex couples, they refused to perform this procedure. They argued that the over-riding ethical consideration in this case was the protection of the surrogate mother from HIV infection. Assuming that her risk of HIV infection outside of the surrogacy arrangement was zero, implantation of the fertilised egg, however much care was taken to reduce the risk of HIV transmission, would result in a higher than zero risk for the woman. The ethics committee of the clinic supported the clinic's decision not to perform the procedure and the reasoning behind it.
Figure 1 AmFAR AIDS awareness campaign, USA, 2003
Adams KE. Gestational surrogacy for a human immunodeficiency virus seropositive sperm donor: what are the ethics? Journal of American Medical Women's Association 2003;58(3):138–40.