Transcript

Preventing AIDS in Africa

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Ilene Wong
Stanford University Hospital
Friday, July 15, 2005; 1:00 PM

Aid to Africa has been a big topic with the recent G-8 summit. Funding development programs in Africa is high on the task list, as is preventing the spread of infectious diseases like AIDS.

Where do we stand on global AIDS prevention? Are we doing everything possible to prevent the spread of HIV at home and abroad?

Ilene Wong, a physician at Stanford University Hospital, has done AIDS work in Africa. She was online Friday, July 15, at 1 p.m. ET to discuss the possibilities for AIDS prevention in the U.S. and Africa.

A transcript follows.

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Arlington, Va.: With the programs to distribute anti-retroviral drugs in Africa - the benefits are obvious, in terms of saving lives, preventing HIV positive babies from being born...etc.

My question is this - Rape is endemic in Africa - witness Darfur, etc. Having many children with as many women as possible is also a large social pattern among men. Assuming men will acknowledge they need the drugs and come forward - how do we prevent a growing population of infected women with the increase in HIV positive men (who've been treated with the antivirals)? What additional complementary programs can be put in place to stop inadvertently causing an increase of people suffering from AIDS?

Ilene Wong: You've hit upon my primary impetus for writing this op-ed: the realization that female empowerment could be one of the most basic forms of HIV prevention. I say one of them because it's such a hugely multifactorial problem, involving culture, gender relations, literacy, economics... in some ways health care is the LEAST involved sector of the AIDS epidemic (I'm exaggerating). I'll pipe in with a few suggestions... But the complementary programs begin with education.

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Washington, D.C.: I've heard that many African men infected with HIV or AIDS believe that if they have sex with a virgin, they will rid themselves of the virus. Is this a widespread belief in Africa?

Ilene Wong: This HAS been a common myth (only one of many) that some have held... but there have also been active education efforts (posters, news articles) to dispel this myth.

South Africa and other nations have done wonderful things to try to make HIV education more mainstream: soap operas, radio shows. But we have to remember that the veil of rumor and mystery surrounding HIV spread/prevention is not limited to African men. I remember a friend with a PhD asking me dubiously, "Can HIV be transmitted through mosquitoes?"

Any area (rural or urban, African or European) that doesn't have good access to education and media will be a breeding ground for misinformation. We have to get the truth out. Of course, there's a huge issue about African trust of neocolonial influence, AIDS has been called the American Initiative to Destroy Sex, etc. And we've seen the damage that misinformation (including the South African health minister's opinion that the African potato is an active AIDS treatment option) does to populations.

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Washington, D.C.: Doesn't the emphasis on the development of Microbicides miss the point about women's right in Africa? If women are not 'allowed' to control their own sexual situations, it seems that the problem will not be solved by new drugs, but by real social and political change. Might the availability of Microbicides give African women a fall sense of security and control over their social situations, when in fact, they are not?

Ilene Wong: Absolutely. But does this mean that we shouldn't provide them with any sort of mechanism? Microbicides (like any "medical" therapy) will only work when coupled with better education and movements toward gender equality. Indeed, there's some concern that vaccines and low efficacy microbicides would actually increase high-risk behaviors.

But we've seen, frankly, that people have sex despite the availability or unavailability of medicines or contraceptives. And we've seen in Africa that just the promise of ARVs (or microbicides) is enough to move people in the right direction - to give them hope that they are not helpless against the disease.

Microbicides are only a SMALL component of the solution. But I believe they fill an important niche that has been overlooked.

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Ilene Wong: Sorry, just an answer to the first question about what can be done:

1) Education, education, education. And this can't just be done by people coming from overseas to do "aid work". People like Nelson Mandela, role models (in television and sports) must step forward to help destigmatize HIV

2) we have to expand programs for voluntary counseling and testing (the elaborate system by which people learn their HIV status, which involves extensive counseling and learning of social support, etc, because of the momentous life changes that occur with learning HIV status). Of course, to do this we'll have to do #1, and destigmatize. Two years ago I was involved in a program hoping to offer testing in schools, but unfortunately we were unable to initiate testing because there was so much stigma in the rural area we were working in that we could not guarantee that our patients would be safe to disclose their status. People with HIV are still kicked out of households and fired from jobs. There's no social support.

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Washington D.C.: Dr. Wong, thank you very much for your compelling article today. I wonder if you could comment further on why you think microbicide research and development is so drastically underfunded? I also wanted to let you and other participants know that they can find lots of additional information on this topic at the Global Campaign for Microbicides Web site at www.global-campaign.org

Ilene Wong: I would say the limitations have to do with #1: target population (less lucrative, and perhaps less advocated for)#2: the perception that microbicides is "small potatoes" - no huge weapon like vaccines. Microbicides admittedly work at a smaller level to help the pandemic - there is a high chance that a developed microbicide would be less than 90% efficacious, which of course dampens enthusiasm for them. But we get so fixated on quick fixes, on "easy" solutions (just get a shot and prevent AIDS) that we tend to overlook more basic (and sometimes more problematic) solutions.

Finally, I can't overlook the scientific difficulties involved in microbicide research. The vagina is a very complex and variable host to work with.

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Arlington, Va.: I've heard from such seminal thinkers as Don Beck, of Spiral Dynamics, how important it is to come in with solutions to a society at a level where the response can be maximized - it may not be what we'd like to do - and it may be very effective. One example he gave was of a rape-prevention device that's been tested in Africa. The women inserts this metal device into her vagina and if she is raped - the device attaches to the penis and has to be surgically removed. Where men know about this device - they refrain from rape as they don't want to experience the consequences and women are safer to go on with their lives and fetch wood, water, etc without being attacked. Have you heard about this and other experiments to really make a difference in women's safety?

Ilene Wong: Wow, I've never heard of that. Will have to look into it. As someone who has always been fond of the idea of punitive castration :) that sounds right up my alley.

The problem, of course, is that if that ever happened to a man, what's to prevent him from being so furious that he does even more damage to the woman in question? And of course there are issues with access, device malfunction, etc.

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Silver Spring, Md.: How much impact has PEPFAR actually had on AIDS in Africa? With its emphasis on abstinence and religion, as well as claims that some of the money hasn't actually been disbursed (Botswana's Gains Against AIDS Put U.S. Claims to Test) it's hard to believe that Bush's claims of dedication to the fight against AIDS hold much water. Do you think the administration is being honest about PEPFAR and PEPFAR's efficacy, and what do you think it'd take for the administration to formulate effective AIDS policy?

Ilene Wong: I have to admit that I have NO data to support my inclinations save what I've read and heard from AIDS activists overseas, but my own person opinion is that PEPFAR is falling short of its potential.

From my own experience, I know that some of the best and brightest workers that I have worked with have tended to gravitate towards NGOs, knowing that the restrictions on their activity will be far less. They just don't want to cope with working with the current administration.

I've always been skeptical of administrative spin, if not administrative honesty. No matter what the administration. Rather than the carefully sculpted statistics that they give, I tend to listen to larger organizations such as UNAIDS as well as anecdotal on the ground efforts.

As to what it'd take for an effective AIDS policy... it's a truism that all aids workers must work with their target populations to draw up area-specific plans, but I honestly have no experience as to how PEPFAR functions on a micro level.

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Atlanta, Ga.: What kind of work are you doing at Stanford? All microbicides?

Ilene Wong: Actually, I'm not currently doing AIDS work while I'm in residency. But in a year and a half I'll be doing dedicated research and hope to do some sort of work with HIV transmission (seminal fluids, etc).

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Boston, Ma.: A lot of attention has been given recently to numbers of people treated in Botswana and the President's Emergency Plan for AIDS Relief. Why can't the media highlight successes rather than the strife? The government of Botswana should receive tremendous praise for being the first African nation to move forward with a plan to treat all of it's citizens. The U.S. government, long before PEPFAR, has supported significant research being run by the Botswana-Harvard School of Public Health AIDS Initiative Partnership on a number of issues including prevention of mother-to-child transmission and strategies for breastfeeding, e.g., that have resulted in great results and findings. Let's hear more about programs that actually do move us ahead in the battle against AIDS.

Ilene Wong: It's an age old dilemma, and I'm not a gloom and doom kind of person, but in some ways I think that underlying the complexity of this issue is important to keep us moving forward, rather than resting upon our laurels.

Best practice following is of course a key element in aid work, and UNAIDS has a slew of publications showing best practice models and successful programs. But the difficulty with this is that I think that the lay public responds much more strongly to problems (in terms of donations, etc) than to solutions. Sad truth.

Of _course_ the US government (and the US people) has already donated a LOT of money to a lot of causes. Of course it should be commended for that. (I won't comment on percentages donated versus percentages devoted to defense budgets) But one can't look at the success in Botswana and rest on it - one has to push forward and see how their strategies can (or may not) work in India, China, etc.

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Washington, D.C.: Thank you very much for your response. I'm not sure I would agree, though, that a microbicide is "small potatoes" compared to a vaccine. Mathematical modeling has shown that even a 60% effective microbicide, used under real life circumstances (i.e. only by some women and not every time) could prevent up to 2.5 million infections over three years in the hardest hit countries. The prevention gap is so enormous that any tool put into the hands of women who currently have no way of protecting themselves could make an incredible difference.

Also, a microbicide may reach the market in as little as five years whereas we're not likely to have an AIDS vaccine for at least another decade. Again, I appreciate your bringing this to public attention.

Ilene Wong: Yes. I think vaccines are the Holy Grail of HIV prevention, which researchers like and gravitate towards. But microbicides could be some large potatoes.

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Fairfax Va.: There is now an abundance of evidence that HIV is not transmitted through Vaginal Sex.

If Anal sex is now the overwhelming transmitter why do you not inform woman that they should at all costs avoid Anal sex and only engage in vaginal sex?

Ilene Wong: I'm not sure what evidence you're speaking of, but I doubt that it shows that HIV is NEVER transmitted through vaginal sex. Certainly anal sex often results in more trauma/bloodflow and has a higher rate of transmission, but vaginal sex absolutely allows transmission of HIV.

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Arlington, Va.: What are you impressions with the almost synergistic effects of HIV/AIDS and TB? The rate of people active with both is growing at an alarming manner.

Ilene Wong: Yes, being HIV positive/having AIDS/being immune compromised will make you more susceptible to TB, as we have seen in New York as well as in Africa. There is some thought that we can actually harness existing directly-observed treatment support for TB (also called DOTS) to better and more efficiently distribute antiretrovirals.

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Washington, D.C.: You mentioned that the vagina is a complex variable. Why is that?

Ilene Wong: For more information on microbicide development, you can check out: www.ipm-microbicides.org.

I'd like to just say one more thing before I leave... please don't fall prey to the sense of helplessness that one can feel when thinking of the magnitude of the AIDS epidemic.

WE CAN ALL MAKE A DIFFERENCE.

Not just with funds. Think of your talents, and what you could contribute. Are you a writer? Write an article, or novel. Are you a film producer? Make a documentary or even a commercial or educational video. Are you an artist? Volunteer your efforts to an NGO for their pamphleteering. You don't have to be a scientist or health care worker. Accountants are needed, economists, social workers. And friends. Just talk about it.

Finally, I just got an email about one grassroots effort for everyone wondering, "what can I do?"... haven't researched the program myself, but:

The UN Population Fund is of course involved in the fight against AIDS and for the status, equality, health and rights of women and girls. For starting and pursuing the 34 Million Friends of UNFPA grassroots effort for the past three years, Lois Abraham and I have received, as part of the 1000 Peace Women Project, nomination for the Nobel Peace Prize. We're trying to get 34 million Americans to send at least one dollar. Maybe you could join our effort and spread the word to a few people. The dollar should go to:

US Committee for UNFPA (34 Million Friends)

POBOX 681

Toms River, NJ 08754-9922

check out 34millionfriends.org

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