HIV vaccine development: would more (public) money bring quicker results?

PIP: Globally, $200-250 million/year are devoted to HIV vaccine research. Most of those funds pay for basic research rather than product development. Moreover, most of the funds are aimed at the HIV strain commonly found in the US and Europe, and not at the strains common to Africa and other developing countries. While US President Bill Clinton set in 1997 a 10-year target for the development of an HIV vaccine, that target date is looking increasingly unlikely. International vaccine and pharmaceutical companies typically drive vaccine research and development. However, concern over the ultimate profitability of developing and marketing an HIV vaccine, and the fear of major litigation should an eventual vaccine go awry have caused such firms to shy away from investing large amounts of money into HIV vaccine development. These companies somehow have to be attracted back into the field. A World Bank special task force is slated to present its report by mid-1999 on possible funding mechanisms to promote HIV vaccine development. It remains to be resolved whether public funds could and should be used, perhaps through a pooled international vaccine development fund. 2 new International AIDS Vaccine Initiative projects are described.^ieng

AIDS in prisons.

PIP: This article highlights the prevalence of HIV inside prisons in Senegal, Africa. There is a general presumption that HIV rates are higher in prisons than in the surrounding population. Organizations have conducted an inquiry on the statistics of HIV infection among prisoners and results revealed that there are existing projects done outside Western Europe and the US. It was observed that prison conditions in Africa do not meet the international norms nor the standards of human rights organizations in their treatment of detainees. One problem that had risen during the Dakar conference was the inaccessibility of condoms among detainees. Furthermore, despite the customs and morale of Zimbabwe regarding same sex activities, there are still reported cases of sodomy without the use of condom. The question presented in this article focuses on the so-called rights of prisoners in practicing safe sex through use of condoms and provision of medical treatment among those infected.^ieng

Vancouver AIDS conference: special report. Rwandan refugee camps: NGOs get rough treatment from both sides.

NGOs attempting to grapple with the thankless task of helping the Rwandan refugee camps have come in for some rough treatment from two directions over their HIV/AIDS efforts. At the policy level, an AMREF paper presented to the Vancouver conference charges bluntly that "There is no policy regarding HIV/STDs in refugee camps among international organizations specializing in refugee crises; thus there is absence of STD drugs and protocols, no privacy in open (tent) clinics, no means of protection (no condoms), and no information regarding STDs/HIV." AMREF bases its comments upon its experience among 700,000 Rwandan refugees in camps in West and North-West Tanzania, an area where (AMREF remarks pointedly) there was previously a low prevalence of HIV by Tanzanian standards, at 2-5%. At the operational level, CARE International, in a conference paper, reported rough treatment at the hands of the Rwandans themselves. It has been working under contract from AIDSCAP among the 400,000 Rwandans who fled to the Ngara district of Tanzania. Not surprisingly, it found that women and girls in the camps faced a higher risk than men. But more surprisingly at first sight, it found that after its HIV educational efforts "negative attitudes about condom use increased from 22% to 78%," which was possibly explained by "political ideology." "Young Hutu men in the camps boasted of their efforts to impregnate as many women and girls as possible to help replenish the population."

Vancouver AIDS conference: special report. The role of the military: to protect society -- and themselves.

PIP: Military personnel are at particularly high risk of becoming infected with HIV because they are in the age group at highest risk for infection, age 15-24 years; they are away from home for long periods of time; many feel invulnerable and ready to take risks; there are usually prostitutes and drugs in military areas; and troops have cash, but maybe not condoms, in their pockets. The level of attention given to HIV/AIDS in the military has grown over the course of the last few international AIDS conferences. One roundtable on HIV/AIDS in the armed forces was held at the 11th International Conference on AIDS held in Vancouver during July 7-12, 1996. A large-scale survey reported at the conference found the level of sexual activity to be significantly higher among US military personnel than in the civilian population. Even the oldest soldiers reported higher levels of multiple partner sex habits than the most sexually active young men in the UK and France. The data further indicate that significant numbers of those men who were infected continued to knowingly have unprotected sex. Data from Angola, Cambodia, Cameroon, the Central African Republic, Congo, Cote d'Ivoire, Thailand, and Zimbabwe show significantly higher levels of HIV infection among military personnel compared to the civilian populations. The authors stress the important role the military can play in preventing the spread of HIV and the need to involve military personnel in AIDS prevention programs.^ieng

Vancouver AIDS conference: special report. Zambia criticised for "missed opportunities".

PIP: Dr. Connie Osborne of the University of Zambia School of Medicine criticized Zambia's government for missing opportunities to strengthen the extent and quality of care provided to people living with HIV/AIDS (PLWA). The government has missed opportunities to get suspected or known PLWA to enter the continuum of care. While HIV/AIDS awareness and prevention have been integrated into all basic health programs, HIV testing is done only in hospitals due to the lack of testing facilities at the program level. Testing, when done, is usually not done properly due to staff shortages, an excessive client load, and/or health personnel burn-out. It is argued that Zambia's health sector reforms fail to address the issue of HIV/AIDS care. Sick PLWA whose serostatus is known to health workers are not exempt from paying user fees at health institutions and most are unable to pay medical insurance. It remains questionable, however, whether exempting such clients from paying user fees would increase their access to effective care. Dr. Osborne noted the case of Kara Counselling, a local nongovernmental organization which has been offering both voluntary counselling and testing since 1993. An HIV test at Kara costs US$0.50. Since January 1996, Kara has tested more than 1000 clients. While approximately 40% of these individuals were found to be HIV-seropositive, only 70 seropositive clients were seen at the counseling service over the same period. Attention needs to be given to this wide gap between client testing and counseling.^ieng

Vancouver AIDS conference: special report. Three African countries to take part in trials to reduce mother-to-child transmission.

UNAIDS has announced that 1900 HIV-positive women in five sites in South Africa, Tanzania, and Uganda are to take part in a clinical trial to evaluate the efficacy and tolerance of three regimens for the prevention of mother-to-child (MTC) transmission of HIV in a population where breast-feeding is the norm. The regimens will use zidovudine in combination with 3TC, compared to a placebo. Some 3 million children are estimated to have been infected via MTC since the HIV epidemic started, and of these, 85% are in sub-Saharan Africa. HIV/AIDS prevalence among children in developing countries is about 35 times higher than in the industrialized world. A trial conducted in the US and France using zidovudine showed a 67% reduction in the risk of MTC transmission. But UNAIDS warns that the cost of this treatment, at about $1500 per mother-child pair, makes it impractical for widespread use in developing countries, where mothers tend to wait more than 30 weeks after birth for their first visit to a clinic, too late for the treatment to start. Breast feeding is another issue. For many mothers, the risk of their infant dying if not breast fed is greater than the risk of transmitting HIV by breast feeding. So the trial will try to ensure that any gains from early drug treatment are not simply lost again through losses due to breast feeding.

How the community copes -- and how not to help the community. Focus: international conference on AIDS in Africa, Kampala.

PIP: As the HIV/AIDS epidemic continues to spread in the context of neither cure nor vaccine, donor fatigue, and arguable results from formal AIDS-control programs thus far implemented, Africa is increasingly regarding its own internal resources as the best available tools with which to combat the epidemic. A World Bank research team which studied approximately 800 households over the period 1991-93 found that households and individuals cope, often successfully, with the impact of AIDS-related deaths; some fail to cope; and for African households, AIDS is but one of many problems with which they must cope. These findings are backed by solid research data, dispel certain myths, and may well influence future aid programs from the US Agency for International Development and other donors. This paper discusses the coping process, lessons about aid, what local organizations do, and a Glaxo Wellcome meeting.^ieng

Condoms and conflict: AIDS and the military.

PIP: Worldwide, many thousands of soldiers are infected with HIV. Their actual or potential presence within the ranks of military forces may generate anxiety among military leaders and general personnel. Troops may be concerned over the risk of being infected with HIV through emergency front-line blood transfusions. Leaders and politicians worry about HIV in the military for more political and cultural reasons, including the potential fallout of being accused of sending troops to spread AIDS on foreign peace-keeping missions. US chiefs of staff have even accused HIV+ servicemen of being comparatively unstable, and that they constitute a security risk, especially where control over nuclear armaments is concerned. These concerns fuel the U.S. military argument for expelling homosexuals from service. Over 13,000 troops identified as homosexual were expelled from the Navy over the period 1982-91. $27 million were spent in 1990 to replace identified gay soldiers. HIV is prevalent to varying degrees in virtually every army in the world. AIDS has decimated some African armies. 1 sub-Saharan country has lost so many pilots to AIDS that it has reportedly recruited soldiers from Yugoslavia to compensate for the loss. Uganda's army may have a 20% prevalence of HIV. War is the harbinger of AIDS; as populations are displaced during war, servicemen turn to prostitutes for sex, and women sell sex to provide their families. Wartime rapes spread HIV and other sexually transmitted diseases. While the military may contribute to the spread of HIV, it also has the capacity to help prevent transmission. Mandatory HIV-antibody testing is many armies may help research and practical efforts to monitor and control HIV prevalence and incidence in populations. Additional steps may be and have been taken by military forces to educate the public and promote and develop AIDS control programs.^ieng

Cost recovery shifts the brand image from Prudence to Protector.

PIP: Social marketing programs are underway in Africa. One program markets condoms in Zaire and Cote d'Ivoire under the brand name Prudence. While a cost element does exist, this program was largely designed to demonstrate the viability of social marketing programs. Emphasis has now been placed upon recovering costs, and condoms are marketed under the name of Protector. Since the US wants to reduce its role as the dominant funder of condom distribution in Africa, and governments and other donors want to be able to buy condoms more cheaply on the open market, the recent cost recovery version of the program will most likely displace the initial version. The Protector program strives toward achieving scale economies and financial self-sufficiency. Specifically, the program aims to standardize campaign materials across all participating countries, make private sector partner organizations in each country responsible for local distribution and marketing, and have earnings pay for a predefined part of program expenditures. Conceptually, Prudence is marketed to prevent AIDS, while Protector is promoted more broadly against sexually transmitted diseases and unwanted pregnancies. Social marketing programs are spreading and condom use is on the rise. The World Health Organization Global Program on AIDS sees its role as advocating condom use and encouraging donors to fund social marketing programs.^ieng