Desicritics Author: Sonal Singh Wadhwa

New Anti-HIV Microbicide Gel Shows Promise

Sonal Singh Wadhwa — Tue, 26 Feb 2008 13:00:26 EST

Experts said on Monday that they were closer to developing a vaginal gel that will give control over sexual health and against HIV/AIDS to women.The study, released at the international conference on microbicide currently being held in New Delhi, was welcomed by those working in the HIV/AIDS field.

Microbicides are products such as gels, creams, suppositories or a long lasting vaginal ring can be applied vaginally or anally to prevent the spread of sexually transmitted diseases, and especially HIV/AIDS.At present, there is no cure or vaccine against HIV/AIDS, and prevention of sexual transmission of the disease depends largely on the use of condoms or abstinence.

This kind of vaginal gel will allow women to protect themselves from HIV and other diseases without having to rely on their partner's decision to wear or not wear a condom.“There is a need for products besides and in addition to condoms that will prevent HIV/AIDS,” said Dr. Sharon Hillier, Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of Pittsburgh School of Medicine.

A number of different gels are currently being tested around the world but none have been proven to be effective to preventing the transmission of HIV.

“There have been disappointments in the field of microbicide,” Dr. Hillier said. “But now there are encouraging studies.”

This latest attempt by researchers in the United States and India is still in the early stages.

Researchers asked 200 sexually-active, HIV-negative women in New York and Pune, India to apply the Tenofovir gel either daily or before intercourse for a period of six months. They were also asked to use condoms in addition to the gel.

Tenofovir, a drug approved by the U.S. Food & Drug Administration, is marketed by Gilead Sciences under the name Viread, an anti-retroviral drug which blocks enzymes that are crucial to the viral production in HIV infected people.

It was found that over 80% of the women in the recently concluded study actually did use the Tenofovir gel as directed.

In 2004-2005, the Cambodian government had ordered researchers to stop a clinical trial to test Tenofovir after protests by commercial sex workers who opposed the trial due to the lack of information of the side effects and provision of health insurance to treat those side effects post the completion of the study.

In the current study, researchers found no disruption of liver, blood or kidney function and found a significant willingness among the women to follow the treatment guidelines.

Dr. Hillier said that 100% of the women in the clinical trial said they would serious consider using the gel if it were approved to help prevent HIV infection.

The UNAIDS estimates that there are 33.2 million people living with HIV/AIDS across the world, of which 46% are women. In high-risk areas such as sub-Saharan Africa, over 60% of those infected are women.

According the Indian government and UNAIDS, nearly 2.5 million people are infected with HIV/AIDS in India and similar to global trends, 40% of those infected are women. HIV/AIDS is believed to be transmitted via sexual contact in 85% of the cases in India.

At the same conference, Dr. Salim Karim from the University of KwaZulu-Natal in South Africa said that if approved, anti-retroviral gels can be used up to 12 hours prior to sex as a protection mechanism against HIV/AIDS.

No Condoms For The HIV-Infected in Switzerland

Sonal Singh Wadhwa — Fri, 15 Feb 2008 06:14:31 EST

Recently, the national AIDS body in Switzerland proposed that those HIV positive individuals who have been taking treatment as per the doctors’ orders, do not show the virus in their blood, and have no other STDs can have sex with their uninfected partners without the use of condoms.

The objective of this proposal is to “alleviate fears of people living with or without HIV and this allow the people living with HIV in Switzerland to have as much as possible a ‘normal’ sexual life.”

In their words:

“The Swiss National AIDS Commission, following a proposal of the special commission of the Federal Office of Public Health on HIV/Aids Clinical and Treatment, after a review of the scientific data and after an extensive discussion, resolves that: An HIV-infected individual without additional STD and on an anti-retroviral therapy (ART) with completely suppressed viremia (in the following: “effective ART”) is sexually non-infectious, i.e. he/her cannot pass on the HI-Virus through sexual contact as long as the following conditions are fulfilled:

• The HIV-infected individual complies with the anti-retroviral therapy (ART), the effects of which must be evaluated regularly by the treating physician;

• The viral load (VL) has been non-detectable since at least six months (i.e. viremia is suppressed);

• There are no additional sexually transmitted diseases (STD) present.”

I find this incredible!

For a disease on which our understanding is still very grey, and we have no cure, I find it absurd that experts in the field would actually give a green signal for HIV positive people to go ahead and have sex without using a proper form of protection. The implications of such a proposal will be visible across the world, including in developing countries like in India where issues like access to HIV treatment and care, gender equality, and basic awareness of the disease are of serious concern.

It may be that HIV positive people in Switzerland are much better off than most living in the rest of world when it comes to access to antiretroviral treatment (ART) and actually adhering to the treatment plan set by the doctor. Most people in India have little or NO access to ART, or they may do the first level of treatment and never be able to afford / have access to the next level of treatment. As per NACO, only 20% of the 2.4 million HIV positive adults in India received ART by December 2007.

Furthermore, gender equality needs to be considered seriously in this scenario. According to the Swiss National AIDS Commission, the decision to have unprotected sex must be taken by the HIV negative partner. It is well documented that women, especially in developing countries, lack the power to negotiate on safe sex practices. So where under usual circumstances, Indian rural women who cannot refuse their husbands from having sexual intercourse with them, will now be bulldozed by their HIV positive husbands into having unprotected sex under the pretext that it is safe to do so!

Another challenge that is likely to come up will be the non-disclosure of HIV status by an HIV positive individual to his/her partner. The HIV positive person may go ahead and have sex with his/her HIV negative partner without disclosing their HIV status thinking that they are not putting their partner at risk. Therefore, the importance of disclosing a health condition, which attracts the inevitable stigma and discrimination, falls drastically.

According to the Swiss experts, the risk of transmission of the HIV Virus depends a great deal on an individual’s viral load. Therefore, my interpretation is that in case the viral load has not been detected in an individual for over six months, then the risk of that person passing on the HIV Virus to his/her partner is not there.

The flaw in this proposal is so very simple. Just because a viral load test is “non-dectable” doesn’t mean that the HIV positive person is cured!!! It may only mean that the level of the HIV virus at this given point of time is lower than what the test can detect.

I cringe to think how many people who may or may not be HIV positive will have unprotected sex simply thinking that they are safe since they follow their doctor’s orders and are going through the ART. Most people, irrespective of education or literacy, will not think even twice about viral load! All that they will hear is ART and Safe to have Unprotected Sex!!! So the buzz on the streets will be that it is absolutely safe to have unprotected sex with an HIV positive person who is taking treatment.

I can just see yet another myth being added to the universal guide to HIV facts versus myths. All these years of hard work will be undone by this one proposal.

Interestingly, even the Swiss experts agree that being on effective ART does not imply that HIV infection can not be passed. If that is the case, isn’t this proposal misleading, especially when it’s so easy to only hear the key words and not the caveats that the Swiss National AIDS Commission has put in?

America’s Center for Disease Control said in a statement “The Commission (Switzerland's Federal Commission for HIV/AIDS) acknowledges that there are no scientific data that the risk of transmission in these circumstances is zero. [CDC] underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners.”

The UNAIDS and WHO issued a joint statement in response the proposal that strongly recommended the “correct and consistent use of condoms” as a proven and effective HIV prevention method for all people irrespective of their HIV status.

Yes, this study issued by the Swiss is encouraging and positive, since this might be the preliminary findings to what may actually turn out to be a way for HIV infected people to lead normal lives. But as I said, these are preliminary. Let’s wait until it is proven and experts around the world agree that effective ART, undetectable viral load, and no STDs equal a normal sex life (aka without the use of condoms!) without any risk of HIV infection.

Fiction: The Silent Companion

Sonal Singh Wadhwa — Fri, 1 Feb 2008 03:20:08 EST

She could feel the screams in her head even before she heard them.

“Waheguru Waheguru Waheguruji,” she murmured, hoping that taking God’s name would slow down the panic within her. “Satnam Satnam Satnamji”

Still holding ironed clothes in her pale hands, Nalini sat down on the lower of the two steps that led to the cosy sitting area within her bedroom. She closed her eyes and thought about why these silent screams in her head had reappeared after so many weeks. She kept taking her God’s name trying to block out blurred images that darted from the left side of her brain to the right and vice-versa.

Feeling the panic rise again, Nalini quickly walked over to the large windows behind the sofa, and pulled back the beautiful gold-threaded silk curtains. The winter sun spilled into the room through wall made of the clear glass, making its way through the small squares on the delicate white silk curtains that sheltered Nalini from any unknown eyes watching her third floor apartment.

Nalini stared out at the world through the curtains, inhaling the warm light of the sun, pulling the light into her body, willing the warmth of the light to enter her body. She felt the warmth spread within her, but somewhere deep inside, there remained an emptiness that felt like a hard cold metal ball. Closing her eyes again, Nalini watched the warmth and the cold fight their battle in her body. Who will win, she wondered, desperately wanting the warmth to take over her entire being, but yet unwilling to let go of that strange cold metal ball somewhere within her.

“Waheguru Waheguru Waheguruji, Satnam Satnam Satnamji,” the chant continued in Nalini’s head.

She noticed that the warmth of the sun was losing this battle. Nalini sensed the iciness spread through her veins, from the center of her body to her heart and her thighs, to her arms and her legs, to her toes and to her fingertips. She felt cold, and yet comfortable with this feeling. She knew what this feeling was. Her silent but possessive old companion had returned to furiously reclaim her from the warmth that was threatening to take her over.

Nalini felt the emptiness spread through her body. Her mind traveled back 11 weeks. She saw herself smiling, excited, happy, and at peace. She was going to be a mother!

And then she saw herself again through the blur in her eyes. Five weeks ago. She lay shivering in a sterile hospital room with two layers of blankets thrown over her. Soft silent tears were sliding down to her ears and into the pillow. With her eyes shining, the doctor walked over to Nalini and gently stroked her hair.

“I don’t know what to say, Nalini. Sometimes these things can’t be explained,” the doctor said quietly.

Nalini gently closed her eyes in mute acknowledgement. And waited for the anesthesia to take over and dim her pain.

“Waheguru Waheguru Waheguruji, Satnam Satnam Satnamji.”

Right to Life: Should the HIV Test be Mandatory

Sonal Singh Wadhwa — Fri, 18 Jan 2008 04:19:10 EST

I was recently asked to write a speech on whether pre-marital HIV testing should be made mandatory. Although I have been working in the HIV/AIDS field for about a year, and I am a little familiar with this subject, I hadn’t given it the serious thought that it merits.

My first instinct was a big resounding YES! Of course, it should be made mandatory. No one should be put at risk for HIV/AIDS infection. After all, even though now infected persons can lead full and healthy lives for many years, it is a dangerous disease that not only an individual has to live with for his/her entire life, but also dumps emotional and financial burden on his/her family.

In addition, one is always at a high risk of transferring the Virus to someone else – a partner or to a baby. Also I have come across enough stories and incidents where a young woman would be married to an individual like you and me, and would find out during her pregnancy to find herself infected, with her in-laws either in the know of her husband’s HIV status or with the full blame of the infection placed squarely on the poor girl’s shoulders. I also know that it can happen the other way around, with the young woman infecting the man that she marries.

Yes, definitely a premarital HIV test is necessary.

However, as I studied this in more detail, I came across some arguments against what seems like a completely logical position to take on this subject.

Firstly, the UN guidelines state that NO ONE (not the central government, not the state government, not the doctor, not the nurse, not the counsellor, not the brother, sister, father, mother, wife, child – NO ONE) can force an individual to test for HIV/AIDS. Okay. So you can’t do mandatory testing. However, you can advise patients to get the test done as part of routine medical care as suggested by the UN. And most importantly, once an individual or couple does get tested, there should be mandatory counselling to ensure that they are made aware of HIV/AIDS, its risks and prevention methods. Also, if this test is made so routine, there will be heightened awareness of HIV and it will no longer be something that happens only to people we don’t know.

Secondly, even if an individual does get tested and the result is a negative, there is no guarantee that the person does not have the Virus. It usually takes up to 3 months for the HIV antibodies to show up in a person’s blood, and in some cases, up to 6 months. That’s scary, eh? What is one to do if the groom contracts the Virus during a really rambunctious bachelor party the night before his wedding?

Recently, an intern with my organization (Lets call him A.H.) stopped on the road to help an accident victim. The victim was an auto rickshaw driver, who was bleeding profusely and was stuck under his vehicle. A.H. got off the vehicle he was travelling in, and helped get the injured driver out from under the auto rickshaw, and in the process, cut his hand. He didn’t think much of the cut on his hand at that moment. However, later, his room-mate (also an intern with us) cleaned the wound on A.H.’s hand and wondered if he was at risk of contracting any blood-borne diseases, especially HIV/AIDS. That was a scary moment! I can see that thought crossing his mind – the thought of having to live with HIV/AIDS for the rest of his life – just because of a good deed that he did. The next morning we called the doctor who basically told us that there was NOTHING that we could do at that moment, and had to wait at least 3 weeks or more for the Virus strain to show in a blood sample, and then too it would not mean that A.H. could be certain that he is HIV negative. To be absolutely certain, A.H. would have to get tested again six months after the incident. Imagine being on tenterhooks for six months to know whether your life has been altered permanently.

Fortunately, today we have very advanced tests that can give very accurate results within 3 weeks of an infection. Prohibiting factors with the PCR test are that this test is very expensive and not easily available. Therefore, logistically and financially speaking, most young Indians would need to wait 3 months to know their HIV status.

Other arguments why HIV tests should not be made mandatory include Stigma and Discrimination. How would an individual, who happens to be HIV positive, even think of leading a normal life in a society where external image is all that matters? In response to this, I would say that why not keep the HIV status confidential? We keep salaries confidential. We keep our private lives confidential. Then why not our HIV status, with the caveat that the spouse or the spouse to be must be informed.

So what it all boils down to is - pre-marital HIV test allows for a RIGHT to a safe happy life that a couple can choose to take. However, our own pre-conceived notions about the disease, our family's discomfort and our society's mental block may stop many of us from taking up this right. But at times, something as insignificant as our pre-conceived notions can end up being a matter of life and death.

And therefore I believe it’s simply question of one’s right. What about you?