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August 18, 2006
IAC: Fifty Ways to Protect Your Lover
by Cindra Feuer
August 18, 2006—At the International AIDS Conference (IAC) closing ceremonies this morning in Toronto, UN Africa envoy Stephen Lewis brought up a most unexpected topic: his, er, private parts. Recalling a meeting in Zambia where a local leader revealed he belonged to an ethnic group that favored circumcision, Lewis (who is Jewish) responded that he did, too. “And there followed a male bonding amongst all the circumcisees,” Lewis told an uproarious audience.
It was yet another sign that “new prevention technologies” had shouldered their way into the HIV spotlight. After 25 years with condoms as the backbone of prevention, health researchers have set out to augment the traditional protective interventions with some biomedical tools that sometimes verge on the sci-fi.
This year’s IAC finds the theme of HIV drug treatment giving way to prevention, in fact. The argument is that it is simply not affordable to keep treating 4 million new infections each year—some 14,000 new infections a day. As Bill Gates, the bankroller behind a lot of these new methods, told a rapt crowd of thousands this week, “We have to understand that the goal of universal treatment…cannot happen unless we dramatically reduce the rate of new infections.”
Some of the biggest excitement surrounds research on microbicide gels that protect vaginally or rectally, not just because the science is moving right along but because the AIDS community has learned the hard way that leaving protection up to men has its drawbacks. “Men are resistant to using condoms,” in the experience of Yuet Lin Yim, a sex worker from Hong Kong. “We hope microbicide research will show success, because we need to take initiatives to protect ourselves.”
Five first-generation candidates are in late-stage clinical trials now, with results expected in 2008, but experts are looking with even more enthusiasm at second-generation microbicides that would use antiretroviral compounds.
Then there’s the pill: Pre-exposure prophylaxis, or PrEP. Trial data announced yesterday showed for the first time that the nuke tenofovir (sold as Viread in the United States) is safe to use in African women. “Now that tenofovir has been demonstrated to be safe and acceptable…it is crucial to determine if tenofovir can effectively reduce the risk of HIV infection,” said primary investigator Leigh Peterson. Ethical questions about these trials came up at IAC, but there was less open confrontation on the matter than at the 2004 IAC in Bangkok.
Male circumcision has been around since the Old Testament, of course, but it’s only recently that a connection to HIV was suspected. The first ever circumcision trial showed in 2005 that men without a foreskin have a 60 percent lower risk of HIV infection. “Even in the most remote parts of Africa, there is now an awareness of the issue; it’s important to act on it,” Lewis told delegates today. “The men are lining up for the procedure in Swaziland.” Trials are underway in Kenya and Uganda to confirm the hopeful findings.
Researchers are also hoping the anti-herpes (HSV-2) drug acyclovir will emerge as a tool for HIV prevention. Data suggest that this disease, which occurs quite commonly in the U.S., increases HIV risk. “Fifty percent of new cases can be attributed to HSV 2,” said Canadian researcher Rafick-Pierre Sekaly at this morning’s science summary session. Two large-scale clinical trials are underway. One in Africa, Latin America and the U.S. that’s studying acyclovir treatment in HIV-uninfected people expects results in 2007. The other trial looks at herpes treatment in HIV-discordant couples in Africa, and is looking to 2008.
Finally, we should see results next year from studies in South Africa and Zimbabwe on the HIV-blocking abilities of cervical barriers such as diaphragms and caps. As this particular theory goes, most HIV infections of the genital tract occur in the cervix, and inserting a barrier may reduce risk.
Wait. “May” reduce risk?
The future is not now, and the growing focus on developing new technologies does have some prevention advocates worried. They fear the sidelining of existing methods, including condoms and needle exchange. And they see time and energy being diverted from the political and scientific battles being waged over current prevention programs, such as those sponsored by the U.S. Presidential Emergency Plan for AIDS Relief (PEPFAR). Jodi Jacobson of the Center for Health and Gender Equity says, “We should be grappling with the harsh realities of today by fighting for safer sex.” (Check out www.timetodeliver.org for more about that.)
Others feel the urgency of the moment is being overlooked. "People are getting infected now. While we applaud discussion and research into new technologies, we are still not using what we have available today,” said Steve Kraus, Chief of the HIV Branch of the UN Population Fund. “The condom already exists and it hasn't been delivered. It works and represents the best tool we have in the fight against HIV/AIDS."
The hope is that this is not an either/or equation. South Africa’s Gita Ramjee, who works with the Medical Research Council and oversees seven prevention studies scattered thoughout rural and urban areas in her country, says she finds herself explaining repeatedly that the new innovations are not in lieu of the old.
“We’re adding to the mix,” says Ramjee. “We’d be wrong to focus only on the current technology.”