Posts Tagged ‘HIV/AIDS’

The fourteen weeks old strike by doctors in Lagos State may have ended. But it left in its wake sorrows, tears and blood. Among the affected communities are people living with HIV and AIDS in the state. According to Ibrahim Umoru, Coordinator of the Network of People living with HIV/AIDS(NEPWHAN)in Lagos, the strike was a nightmare especially as it affected  access to life saving antiretroviral and other quality  monitoring and follow ups.

As the world marks World AIDS Day(WAD), many are celebrating  achievements recorded in the global AIDS response  especially the 2010 Global AIDS Report published by UNAIDS which indicates a reduction in the rate of new infection and as well as access to treatment. But for Lagos state, the death of PLWH during the strike by doctors should be a cause for all to be worried as their death were indeed avoidable.

To mark this year’s WAD,NIGERIAN HEALTH JOURNAL reflects on this seemingly glossed over tragedy in this interview with NEPWHAN’s Ibrahim Umoru.

As someone representing a community that was at the receiving end ,what would you consider the cost of the suspended strike by doctors in Lagos?


The cost is enormous to the citizenry generally and particularly heavy to People Living with HIV (PLWH). You will agree with me that in the management of HIV, one gets to see a doctor quarterly. That is for patients who have been on treatment for long and are stable; while those who just started treatment would have to see their doctor say, monthly. It’s so worrisome for our secondary hospitals where our nurses have not been strongly grounded in triaging*. Many people who could not afford private hospitals resorted to taking traditional herbal medicines and those who had no choice actually died.

That means the strike led to treatment interruption for many PLWH…what is the implication of this on AIDS control in the state especially with the likely issues of drug adherence and resistance?

There can’t be anything closer to the truth than this. You know there are various categories of PLWH. Some have vast treatment literacy experience while some were just  initiated into treatment and others were  just about to start treatment . The implication is that those who have been on treatment for a long and time and are experienced and  have become very stable but within the period of the strike there can’t be  any quality evaluation of tests done .Also, there were no consultations for opportunistic Infections(OIs)  just in case any was present. Patients were just coming to pick their drug refills without doctors’ examinations that are routinely done quarterly for this class of patients. However, some are not that experienced and worst of it is OIs could just come up within that period and the only alternative is private hospitals. How well informed are doctors in private hospitals with regards to the management of HIV and AIDS? So, that becomes an issue. I lost a close client to complications resulting from opportunistic infections. I have  another PLWHA who committed suicide that period too. These are some of the numerous painful losses to us in the PLWHA community resulting from the strike.

Is it true that knowing the consequences of a strike on PLWH some doctors in a particular treatment centre tried to ensure that there were no treatment interruption despite the strike?

Yes! Very well yes. I am aware of a particular doctor that took all the risk to be available for some days to PLWH during the strike. This is very commendable as the risk was enormous if his colleagues  had found out. That to me is the height of humanitarianism.

So, what becomes the fate of PLWH who died during this strike? Are you making your case known to Lagos State has that become one of the many casualties of being HIV positive in Nigeria?

Definitely, I am going to make a case to Lagos state as am trying to collate data from the various treatment sites around. At least, we have it on record. But come to think of it, can they bring back those lives again?

What could have been done other wise to prevent these needless deaths even in the face of the strike?

There is great need to improve the skills of nurses in triaging and palliative care. However, our leaders have to be more sensitive and proactive in the welfare of workers generally and health workers particularly. What the doctors were asking for were not out of the moon. They were things they had all negotiated and agreed upon long before now.

Someone has argued that doctors should get a bit more creative when considering a strike action given the implication of a doctors strike. Do you think so?

Our leaders and policy makers should be more creative and compassionate too. The problem is when most of them get there; they care no more about the populace. This should not be so!

So what can be your advice regarding the best way for doctors to strike without downing tools especially when you consider the fact that when their needs are finally met, they cannot bring back the lives that  have been lost?

The underlying fact is we should not allow issues to get to the point of strike at all. A strike that lasted for months is a reflection of the gross insensitivity of the people at the top. They don’t attend these hospitals as they and their families get health care outside the shores of our land. The people need to ask questions. We need to engage our various representatives in the legislative arm of government. The government too need to engage with the populace as they are too far away from the people they govern. These lives as you rightly attest to cannot be brought back. We should be more proactive in leadership and be on ground with the people.

For PLWH on treatment and for AIDS support groups, what lessons have been learnt from this ugly experience bearing in mind that  workers strike in Nigeria is now a way of life and healthcare workers are not left out?

We need to address our positive living lessons more creatively and increase the treatment literacy efforts in the support groups. Most importantly, we need to engage the government particularly in Lagos state to make sure we are heard at the right quarters. To this we have started restrategising to engage with government. You would recall  that the Lagos state government has a law in place protecting PLWH and a section of that law provides for a board and PLWH are supposed to  be part of that board that focuses on fund for drug buffer for people living with HIV. Furthermore, we wish to engage with Lagos State AIDS Control Agency( LSACA) to find out the composition of their board as the law that sets up such agency up to NACA provides for our representation there. That way we can be heard.


*prioritization of patients for medical treatment: the process of prioritizing sick or injured people for treatment according to the seriousness of the condition or injury: Microsoft® Encarta® 2009.


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As we conclude our discussion on the role infertility is playing in swelling cases of violence against women and the attendant health implication especially the spread of sexually transmitted infection, perhaps it won’t be out of place to ponder on the words of Dr. Oliver Ezechi.

In a recent interview with NIGERIAN HEALTH JOURNAL, Ezechi who is consultant Obstetrician & Gynaecologist and Chief Research Fellow and in the Sexual and Reproductive Health Research Unit of the Nigerian Institute of Medical Research, Lagos said:

“The pressure from society forces men infertile relationships to engage in extramarital affairs to prove their manhood. Now, because of the intense pressure, some women will also go out searching for pregnancy especially if they suspect the fault is from the man. This is so that the woman can be at peace, save her head and shut the mouth of everyone because sometimes the torments from family members can push people to unimaginable length.”

This is puzzling, to say the least. To think that there is a married woman somewhere, currently having affairs with other men(with the approval of her husband; by the way) so she can get pregnant and protect him from society’s ridicule is  one of the weirdest thing to imagine let alone do.

It doesn’t make sense to any observer who is not too conversant with the African society and how it is dealing with

African women:when will your jubilee come?

issues of infertility. But these stories are real and like some public health physicians and epidemiologists may have realized, have added to the list of harmful cultural practices believed to be driving the HIV/AIDS epidemic in most African societies.

Part of what this reality suggests is that  perhaps, marriage is becoming particular risky and dangerous for an average African woman as it appears that she is even more exposed to HIV in marriage than as a single woman.

Doesn’t this provide the basis for interrogating some of the cases of HIV sero-discordance we’ve had to deal with in Africa?

Dr. Ebun Adejuyigbe, consultant pediatrician and associate professor, Obafemi Awolowo University, (OAU) Ile Ife, Osun State would rather say an emphatic yes to that poser and she has a strong case to support her stand.

Just  in case you are wondering “HIV discordance refers to a pair of Sexual partners in which one is HIV positive and the other is HIV negative.”

After studying several cases of pediatric HIV infection she and her colleagues have had to deal with over a period of time  and the fact that only the mothers of the children were the ones with HIV, Adejuyigbe soon discovered that sterility or sexual impotency and infertility were all at the root of the whole problem.

“We discovered that these women  with HIV positive babies apparently were encouraged by their husbands to go out and be impregnated by another man. The choice of man the woman decides to opt for would be determined by the possession of certain physical features that could clear any possible doubts about the child’s paternity. No one would ever imagine that a man irrespective of his medical condition would allow his wife to go out and get pregnant by another man and pose as the father when the child is born”, said Adejuyigbe.

That is the norm in some parts of Nigeria and the women in a bid to shield their husbands from social stigma that comes with sterility or impotence would actually go and have sex with another man and come back pregnant for her husband. But these days, the women are not only coming back pregnant. They are also coming back infected with HIV. And their husbands may  never get infected especially for those whose husbands are sexually impotent.

“I never knew this was happening until we started noticing an unusual trend at the pediatric ward in OAU. We were seeing several sick children, infected with HIV and expectedly ,you will have to talk to the parents of such kids and after encouraging the mothers to go for HIV counseling and testing; the result is usually positive”.

That is often the beginning of several revelations according to Adejuyigbe, especially if the clinician insists that the father of the child should also be tested for HIV.

“The women involved would wonder at our display of naivety if we conclude that the man probably would also be infected with HIV. But they will tell us emphatically that their husbands cannot be HIV positive. Of course, you want to ask is he not infected and the women would tell you their husbands can never get infected because “he doesn’t, and can’t have sex with them. If you probe further they will tell you because he is impotent”.

This development was confirmed following further survey and interview of several women visiting the pediatric ward with children infected with HIV. The women are counseled to go for HIV test and if the result turns out positive, they are usually not in doubt as to the source of the infection.

It all started as a problem of infertility and the need to shield themselves from the social stigma that  infertility attracts. One partner decides to cover the shame of infertility they both will have to live with and it turns out that she is actually laying down her life.

Again, the question many would want to ask is ‘how can men protect their wives from society’s ridicule if indeed she is medically confirmed to be the one with the problem that has caused the couples infertility?’

Marrying a second wife or even divorcing the woman has been the norm for most men. If a woman could decide to get pregnant by another man just to protect her husband from the shame of sterility(and eventually get infected with HIV)then men should start thinking of a better sacrifice to make when the table is against their partners.

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Ibrahim Umoru

At the early years of the HIV and AIDS epidemic when treatment was a mirage, a woman testing positive to HIV gives up hope of bearing a child for the fear of having HIV+ children.

With the advent of robust treatment, care and support; our women folks taking advantage of Prevention of Mother to Child Transmission(PMTCT) services smile with relief for the ability to have babies who are HIV+. What a wonderful world!

However, as a father, a husband and somebody living positively and constructively with HIV, I sure do have a role, in fact a bold and big one at that, in my wife’s effort at accessing PMTCT. I play strong roles in supporting my wife on treatment to attain a robust CD4 count and undetectable level of HIV in her blood. It is my responsibility to make her have a good nutrition and maintain a good health as well as encouraging safer sex to the time of peak ovulation. This is to reduce re-infection.

One of the ways to prevent mother-to-child transmission of HIV involves a long course of antiretroviral drugs and

Make sure she sees a midwife:Living up to his responsibility beyond just getting her pregnant:source:africanfathers.org

avoidance of breastfeeding, which reduces the risk to below 2%. In developed countries ,the number of infant infections has plummeted since this option became available in the mid-1990s.

Since 1999, it has been known that much simpler, inexpensive courses of drugs can also cut mother-to-child transmission rates by at least a half. The most basic of these comprises just two doses of a drug called nevirapine – one given to the mother during labour and the other given to her baby soon after birth. These short-course treatments, combined with safer infant feeding, have the potential to save many tens of thousands of children from HIV infection each year.

However, for the whole robust course of a full ARV regime, opting for elective CS, alternative infant feeding; men’s roles are obviously essential and we MUST be there for our female partners.

It is important to note that as husbands we have a role to play to make the period of pregnancy less stressful for wives and always be there for them and for the union too. In encouraging my wife to consent to elective caesarian section, I continued with such support and was in the theatre by her side when she had her baby.

This is my opinion about men being part of the solution rather than the problem. We played a role in the pregnancy and since we cannot carry it (the pregnancy) we should be responsible enough to support and  encourage the woman till she enters the labour room.

If we all agree with this summation, then we can collectively agree that the term PMTCT which is Prevention of Mother To Child Transmission of HIV  should  be broadened to  read PREVENTION OF PARENT TO CHILD TRANSMISSION OF HIV (PPTCT). We all should work for that success as I and  my darling wife continues to celebrate the birth of our latest baby born HIV free baby.

Have a pleasant day!

Ibrahim Umoru

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Ibrahim Umoru

When HIV is in the family, divorce comes knocking, love flies out of the window. This seems the story of most homes affected by HIV. And Im really hoping we can stop this trend..and that is why I appreciate the opportunity offered by Nigerian Health Journal to educate subscribers to this blog on HIV sero-discordance and how we can protect ourselves and our families against HIV infection. And just in case we are already infected or affected by the virus, how to live a happily and fulfilled life.

Like the Moderator hinted earlier I will be sharing mostly my experience on this blog how I have been able to live with HIV for the past 10 years and counting as well as experiencing gained form helping families affected by HIV stay together and strong

It won’t be out of place to set this discourse rolling by providing some background information to help us understand what sero-discordance is all about.

HIV discordance refers to a pair of Sexual partners in which one is HIV positive and the other is  HIV negative. This condition has caused several painful, dreadful experiences in once beautiful marriage. When HIV infection enters the family, it heads straight to the root of the relationship and starts breeding discords, suspicion and worst still dissolution of the relationship. All thanks to the high rate of stigma and discrimination encapsulated in the robust level of ignorance in the society.

Whenever a married man or woman gets infected with HIV something else very precious to that individual also gets infected. Suffice to say that the first target of attack as soon as HIV infects a married person is his/her marriage. It is no longer news that many marriages are daily lost to HIV infection in Nigeria. The once loving husband or wife suddenly becomes a foe the moment their spouse comes home with a HIV positive test result.

Divorce seems the next destination and before you know it both partners are heading their separate ways. This would have been less worrisome if they remain lonely. But they are soon involved in fresh relationships thus increasing their chances of either getting infected, re-infected or infecting someone else. But a simple, yet fundamental support by way of education and counseling could help address these anomalies.

No doubt a wide gap exists as far as AIDS response in Nigeria is concerned. This gap includes the need to strategically reduce the number of AIDS related divorces. Marriages must be preserved. Homes need not break or disintegrate with HIV infection. There can be much love after HIV infection. This is why I would rather invest so much in building

Can your marriage withstand it when the HIV test says "positive"? source:blackchristiannews.com

HOMES than just building Houses!

Two types of HIV discordance have been identified in the course of our work.

Soft Discordance or Discordance Simplex: This is a condition where the woman is HIV positive and the man is negative. This classification is done based on the need for child bearing. In Nigeria and indeed Africa, childbirth is the icing on the relationship of any couple. In this condition the woman needs to have a relatively high CD4 cells, very low viral load or preferably undetectable and with the support of the medical team and the counselor, the woman  can collect the sperm of the male partner during her ovulation period in a sterile syringe without the needle and introduce it to her vagina. She can get pregnant with this simple method and continue with other Prevention of Mother to Child Transmission (PMTCT) practices as may be prescribed by the medical team. In our environment, the financial cost implication of this practice is very minimal hence I ascribe the terms   ‘Soft’ or ‘simplex’.

Hard Discordance or Discordance Complex: This is a condition where the male is HIV positive and the female is negative. Getting the female pregnant with minimal chance of infection can be very complex. This happens to be so as the sperm of the male which though is HIV free is in the medium of the semen that carries HIV, hence would have to be separated from the HIV carrying semen before introducing it into the woman. The financial cost implication of this procedure, sperm washing and artificial insemination is outrageously high. Most fertility facilities in Nigeria shy away from this practice and rather would refer couple in this condition to facilities in South Africa and Europe. This is most regrettable and frustrating to the couples and even the supporting counselors too.

With robust counseling support over time, it has been prove couples could live happily. Hence, our national response to HIV need to bridge the gap that exist in the peculiar need of this group by increasing the services of the tertiary HIV care centers  to include sperm washing facilities and expertise while enhancing couple communication and disclosure.

Ibrahim Umoru

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Kingsley Obom-Egbulem, New Delhi

Mr. Kapil Sibal, the Indian Minister for Science and Technology and Earth Sciences had thought that his audience at the closing ceremony of the 5th Microbicides Conference in New Delhi, India may include some people already losing patients at the slow progress being made towards finding a safe and effective microbicide.

So, he probably took a quick lesson on how to motivate and encourage despaired microbicides researchers, advocates, funders and of course trails participants.

People don’t understand what research is all about, Sibal said. Research is simply the validation of hypothesis. You have to make it clear to funders that research is a long term effort and success is built on failure.

It is not too certain how well the octogenarian’s motivational speech was received especially by delegates who felt the quest for microbicides has dragged on for too long, but it gave some others enough reasons to count their blessings.

Dr. Peter Piot the UNAIDS Executive Director had earlier exprresed optimism that the world is closer to a microbicides than when it first started. I am here today because I believe that one day we will have a microbicides, says Piot.

Who wouldn’t believe him especially after sharing some historical facts and helping everyone to understand that the journey may be long but it is steady and on course.

It took 50 years to develop a polio vaccine. It took 40 years of clinical trials to come up with an effective treatment for pediatric leukemia and we still don’t have truly effective vaccine for tuberculosis or cholera& and the fact that some microbicide trials ran their full course is something to cheer about.

For Piot, even though scientists have nothing to show the world yet as far as safe and effective microbides is considered, they are certainly learning along the way and key among the lessons learnt so far is how not to develop a microbicides.

We are learning a lot of lessons about methodologies and developing new principles around prevention research, he says.

What started in 1992, in form of small but significant streams of funding from the US National Institute of Health(NIH) for minor research work around microbicides has grown into $131 million between 2000 and 2006 this aside from European Funding which has grown from $700,000 to $56million within the same period.

This learning process has seen several products coming up for trials and not making it through.

From Acid Buffers -which maintains an acidic level within the vagina to Adsorption inhibitors -which prevent contact or attachment with target cells,Entry/fusion inhibitors – which prevent virus fusion and entry into target cells to Replication inhibitors which block viral replication.

There are also Surface-active agents (also known as surfactants) which inactivate or destroy viruses or bacteria by disrupting their outer envelopes or membranes.

HIV simultaneously enters two different types of cells in the vaginal epithelium (outer lining of vaginal cells) associated with the immune system — Langerhans cells and CD4+ T-cells.

With most of the candidate microbicides already tried recording some shortcomings which made them either unsafe (even when they had effect on HIV) or not too effective against HIV within the vagina, the search now has gone the direction of ARV-based microbicides .These are microbicides products made from antiretroviral. Since ARVs affects the progress of HIV in the body, it is believed that they can also affect the virus within the vagina area.

The Tenofovir Gel is the most current within this class and series of clinical trials done on the gel seems to have indicated unprecedented hope for the future thus qualifying it for effectiveness trials like  drug absorption trial among pregnant women and another trial to evaluate dosing strategy timed around sexual intercourse.

Of course, the concern about ARV drug resistance( if a woman using ARV based microbicides for prevention eventually tests positive) seems to be standing in the way of ARV-based microbicides such as Tenofovir. It is a hurdle researchers are bent on crossing when they get there.

In moving ahead Piot’s counsel for the research community seems indispensable and top among this is the need for more rigour in selecting which products moves to the next stage of clinical trials and the need to avoid offering too much hope where there is none.

I worry that we set ourselves up unnecessarily for failure by over- hyping what we hope to achieve and by not doing enough to explore and share what can be learnt through trials.

Enough lessons learnt already. But what roles these lessons would play in shaping the outcome of the next phase of clinical trials is not any body’s guess.

First published March 7,2008


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Kingsley Obom-Egbulem, New Delhi

For journalists covering the 2008 Microbicides Conference in New Delhi, India, one session that may remain remarkable for a long time was the media conference held on day two of the conference.

Arguably, the media conference seemed unprecedented.

Check out members of the panel and you can imagine the quality of deliberations: all the M2008 Conference co-Chairs-Dr. Gita Ramjee, Director, HIV/AIDS Research Unit, Medical Research Council (MRC) South Africa, Dr.Nomita Chandiok, Deputy Director of Reproductive Health and Nutrition, Indian Council of Medical Research, (ICMR), Delhi and Dr. Badri N. Saxena,Professor, Centre for Policy Research, New Delhi,India.

Also present were Ms. Lori Heise, Executive Director, Global Campaign for Microbicides(GCM),Dr. Sharon Hillier, professor of obstetrics and gynecology, University of Pittsburgh, USA and Dr. Salim Abdool-Karim, clinical infectious diseases epidemiologist and Pro-Chancellor at the University of Kwazulu Natal, South Africa.

Aside the caliber of speakers that featured, the media conference provided opportunity for candid questions and remarks from the panel and media professionals in attendance on microbicides research development.

Expectedly at such meetings, the quality of engagement and outcomes are usually limited to journalistsunderstanding of the issue. That was exactly the case.Aside two journalists from India and a South African journalist whose questions came from an informed perspective, others simply made the media conference seem more like a media briefing or a monologue.

The event must have been an attempt to update journalists about goings on in the microbicides research clime by creating a platform for journalists/researchers parley for the good of every one waiting earnestly for a safe and effective microbicide.

Was the event appropriate? Certainly yes! Was that the best way to go about it? Of course not!

I think the role journalists can play in the global microbicides research and development agenda needs to be properly articulated and steps taken to incorporate it as part of a holistic efforts not a cut and paste, quick fixapproach, otherwise microbicides researchers may continue to wonder whether or not journalists are friends or foes, says Olayide Akanni Executive Director, Journalist Against AIDS (JAAIDS)Nigeria.

Akanni spoke the mind of a Zambian journalist in Cape Town 2006 who was embarrassed to see researchers and investigators from his country, who would rather die than grant interviews blowing hot at sessions and even blaming journalists for not coming to seek for information.

Most of these researchers only speak at conferences, he says.You see them, you even interview them but as soon as they get back home, they will never pick your calls or reply your emails unless again you meet them at another conference.

The media: Friends of foe, was the title of a track D session that actually tried to examine the roles of journalists, communicators and researchers in the interest of microbicide research efforts. Incorporated into this session was a skills-building opportunity on media engagement for researchers and it featured a lot of what to say, what not to say, how to say it and how not to say it.

I believe the media has a critical role to play if we must succeed in our search for a microbicide but I also believe that only an informed media can play this expected role, and we must engage them, let them know what they need to know without filtering thus improving the quality of their involvement, says Manju Chatani, Coordinator African Microbicides Advocacy Group (AMAG) Accra. Not a few people have argued that journalists are a threat to microbicides research development especially in their coverage of clinical trials.The argument is that journalists can jeopardize the objectives of a trial if they are encouraged to keep the issue in the news. But others believe that journalists can be made to see themselves as partners whose interests such research and clinical trials are meant to serve rather than a distance group of people who must not know what is going on when the trial commences and must keep their mouth shut even if the trial hit the rocks.

It is always better to let the media know when you are starting a clinical trial and communicate your limitations with respect to regular updates and coverage of clinical trials so that they can always be there for you during critical moments and even report from an informed and less sensational perspectives. It has worked for us in Nigeria during one of the trails , says Morenike Ukpong, Coordinator, Nigeria HIV Vaccine Microbicides Advocacy Group (NHVMAG).

Ukpong added that because journalists had been briefed and educated about the trials when it commenced, there was no need for any damage control. They knew what was going, they knew it was a clinical trial and like any trial it would be stopped if anything goes wrong and they knew what could go wrong and when it happened there was no need to report falsehood or sensationalize the issue.

It all started from a pre-conference workshop on Health Advocacy organized by a coalition of microbicides advocacy groups at the India Habitat Centre. The media and its role in microbicides research development was not a core focus of the workshop but thanks to what initially seem like a participants unguarded comments. For about twenty minutes, those comments tilted the discussions and opened up a vista into what the next two years would look like as far as the media and reporting of clinical trials are concerned.

Indeed, the next two years can be said to be critical moments for microbicides research development and research advocacy.

With the outcome of the HPTN 059 trial painting an unprecedented picture of progress and hope, there are indications that ARV-based microbicides may just be the way to go. The HPTN 059 Trial assessed the safety and acceptability of an antiretroviral-based microbicides called Tenofovir gel used daily by 200 sexually active women over a six months period.

Results from the study presented at the New Delhi Conference indicate that the tenofovir gel is safe for use every day.

Also in the next two years, the world would await the outcome of two studies:the Vaginal and Oral Interventions to Control the Epidemic-also known as the VOICE Study as well as the CAPRISA 004 Study.While the VOICE Study seeks to establish the effectiveness of an ARV-based microbicides that women can use everyday instead of at the time before sexual intercourse, the CAPRISA Study being conducted at the Center for the AIDS Programme of Research in South Africa (CARISA) Durban is a Phase 2b trial that seeks to evaluate the dosing strategy and time around sexual intercourse when using the Tenofovir gel.

These are indeed critical moments for global HIV prevention efforts and the media can make a whole lot of difference at this time. What dimension this difference takes and its impact would depend largely on how informed the media is, how much of this research efforts they can buy into and own and the quality of trust, partnership and engagement the scientific world can offer.

First published March 3, 2008


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Kingsley Obom-Egbulem, Delhi,India

Dr. Salim Abdool-Karim can easily be described as a feminist when you consider his zeal and commitment towards microbicide research and advocacy.

“I’m very concerned about women and the issues that affect them especially their health”, he says.

And talking about women’s health, you only need to hear him talk about microbicides research and development to appreciate how deep this mans concern is with regards to the health of women.

A Pro-Chancellor at the University of Kwazulu Natal in South Africa, Dr. Abdool Karim is a clinical infectious diseases epidemiologist whose research interests are in microbicides and vaccines to prevent HIV infection, as well as implementing antiretroviral therapy in resource constrained settings.

Just like his ilk in the Microbicides Trial Network (MTN),Abdol-Karim can’t wait to see the development of an effective, women-controlled HIV preventive mechanism.

One day, there was this woman who came into the hospital where I work with her sick child. The child had thrush and looking at him you could tell he is HIV positive. We conducted a test on him and that confirmed our suspicion. The woman was confused. We advised her to test for HIV too. The test turned out to be positive. As I looked at the confusion on her face, I asked myself, what could have prevented this woman from getting infected? If you tell her to abstain, she will tell you she is married and must satisfy her partner’s need for sex.

“If you tell her to insist her partner uses a condom, she will tell you she needs to have children. The solution lies in a preventive method that is controlled by the woman a solution that does not in any way interfere with her relationship or her desire to have children. That is why we are in this quest for an effective and safe microbicides and we need to get it.

But getting the needed breakthrough in this quest for a microbicides hasn’t been a smooth sail. Its been a catalogue of ups and downs. Amongst these downs is the perception of clinical trials as an avenue for trial participants to get infected with HIV.

Indeed people are likely to sero-convert (i.e, become HIV positive) in the course of a microbicide clinical trial. But can it be said that they got infected because they participated in the trials? Could they have been infected with HIV even if they hadn’t participated in trials?

When people get infected in HIV clinical trials, they got infected not primarily because of the drugs being tried but because they were already vulnerable before coming into the trials, says Abdool-Karim.

In health care, a clinical trial is a comparison test of a medication or other medical treatment (such as a medical device), versus a placebo (ie inactive look-a-like). While undergoing the trial, the agent being tested is called an investigational new drug.

Clinical trials are usually done in three phases.Phase I tests the safety of the treatment on a small number of patients. Phase II assesses the effectiveness of the treatment and usually involves a larger group of people. Phase III provides in-depth information about the effectiveness and safety, by comparing experimental treatment with the standard protocol. Phase III trials usually involve several thousand of people.

Trial participants who volunteered to be part of any clinical trial, tend to exhibit some confidence in the drugs being tried which often increases their vulnerability even though they were already vulnerable to getting infected in the first place, but that is not to say that the product being tried infected them like people are meant to believe, says Dr. Morenike Ukpong of the Nigerian HIV Vaccine Microbicides Advocacy Group, (NHVMAG).

Ukpong believe that the greatest challenge facing any HIV prevention research any where in the world is that of finding a safe ground between a laudable intention of trying to test a potential product that will prevent HIV infection and the ethical and even emotional implications of that quest.

No doubt, we need something that can protect women who have no power to say no to partners who are not faithful and who wont use condom, if there is a product with the potential to protect women from HIV,it certainly has to be tested and testing it comes with a lot of issues which we must deal with as they arise.

Some of these issues are really not clinical but sentimental, ethical and borders about fundamental rights.

The target participants in any microbcides trials are vulnerable people-poor dis-empowered women, sex workers who are daily exposed to the risk of getting infected with HIV due to their work or normal day-to-day life.

Lori Heise, Executive Director, Global Campaign for Microbicides(GCM) lends credence to this notion.

If you have to do microbicides trial, you have to go to where you have women who are very vulnerable, women who do not have the power to control where and when and with whom they have sex and that is not very easy.

Since clinical trials are fundamental hurdles that must be crossed in the quest for safe and effective microbicde that can protect women against HIV infection, how can this hurdle be crossed without reinforcing the guinea pig perception most people have about trial participants?

We need to let these women understand the risk they are taking and also let them understand their rights in relations to such trials, says, Heise

That is definitely one way out. But how easy is it in practice? To what extent do researchers go to translate the care on paper into reality when it is needed?

In 2006,GCM conducted a mapping of standard of care at microbicide clinical trial sites. The exercise looked at the prevention services provided to women enrolled in large-scale microbicide effectiveness trial.

We were actually at trial sites to ensure that what is promised is what being offered in terms of care and our overall, microbicides studies are meeting or exceeding the ethical obligation to provide access to proven prevention interventions, including risk reduction counseling and provision of male and female condoms when requested, says Heise.

It is uncertain if the issue of sero-conversion will ever be addressed considering the emotional perspectives to it. But like Dr. Bode-Law Faleyimu a researcher, gynecological surgeon and a member of NHVMAG puts it, there is a need to ensure we have done what is right for the common good.

There is a way your mind feels when you know you have done what is right before all. This issue is about conscience, it’s about right, it’s about justice and equity, like ensuring that those who were part of the trials and research are among the first beneficiaries, but you know this is not always the case.

Perhaps here lies the challenge for future trials.

The GCM report on Mapping the Standard of Care at Microbicides Trials says, the field of microbicides research is making ethical progress. However the report says local community involvement from the conception of a trial onward is still insufficient. Decision-making on standard of care is often obscured at the top, with ill-defined or inconsistent donor policies that restricts what is considered possible and the ability to meet ethical demands.

Sounds like a corroboration of Faleyimu’s admonitory gesture.

First published March 3, 2008


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