Women and HIV: research directions
Forum for Collaborative HIV Research
The symposium, a follow-up to the 2002 “Sex & Gender in the Management of HIV Disease Care, Prevention and Research workshop was designed to focus attention on research needs specific to women and HIV. Three themes from the frontlines of HIV care and prevention research were chosen for discussion: new approaches to prevention, addressing underlying social needs, and special needs of women in conflict and post-conflict settings. These were addressed from the researchers’ as well as the community perspective. A third objective was to stimulate increased funding opportunities to address these research needs.
The symposium was co-chaired by Judy Auerbach, Vice-President for Public Policy for the American Foundation for AIDS Research (amfAR) and Kathleen Squires from the Keck School of Medicine, University of Southern California. Veronica Miller, Director of the Forum for Collaborative HIV Research introduced the Forum, the symposium objectives and the research themes to the participants. A specific research example illustrated each research theme, ranging from ongoing and funded research projects to research concept ideas in search for funding.
New approaches to prevention: use of ARVs in pre-exposure prophylaxis
Use of antiretrovirals to prevent HIV infection is neither a novel nor unfamiliar concept: its efficacy in prevention of mother-to-child transmission is well established and widely accepted. As an intervention in high-risk but HIV-negative adult populations however, it certainly is novel. Kimberly Page-Shafer, from the Centre of AIDS Prevention Studies, University of California, San Francisco reviewed the current thinking on, and rationale for, the use of antiretrovirals to prevent HIV infection by sexual transmission. If successful, this approach may be of significant benefit to women who are frequently especially vulnerable due to social, economic and biological factors. Potential benefits include prevention of HIV infection, prevention of secondary cases, and availability of a personal and private prevention method that women can control. Dr Page-Shafer is the principal investigator for the Cambodian HIV Prevention Study, “Kdey Sonkum Roboh Satrei” – Hope of Women, sponsored by the US National Institutes of Health (NIH) and Family Health International, with collaborators in Cambodia, University of New South Wales and at the University of California, San Francisco. This placebo-controlled, double blind trial plans to recruit 960 female HIV-negative sex workers over the age of 18 to be randomised to placebo or once-daily tenofovir.
Addressing underlying social needs
Prevention research has focused primarily on individual risk, behavioral change models and technical interventions. There has been a growing recognition of the importance of structural factors, such as poverty and economic inequalities, gender inequalities and mobility and migration and their impact on individual behavior. Interventions targeting structural factors are those that alter the context in which health is produced, including laws and policies, cultural norms, and interventions that affect the physical environment and socio-economic conditions. Although the importance of structural factors in health matters is recognised, few examples of studies designed to address these exist. Julia Kim reviewed the issues associated with research of structural interventions to address underlying social/structural vulnerability of women to HIV. Barriers to structural intervention research include lack of tools to conceptualise and mount broader social and economic interventions, as well as the requirement for new partnerships across multiple sectors and disciplines, for a shift in emphasis towards concepts of community participation, and for innovative and complex experimental methods. Not least, structural interventions may challenge firmly rooted political, economic and social interests. The disease-focused and vertical funding mechanisms in place make obtaining funding for this research a challenge.
Dr Kim runs the RADAR (Rural AIDS and Development Action Research) Programme, a partner in the IMAGE (Intervention with Microfinance for AIDS and Gender Equity) study. The IMAGE is a multi-faceted research programme, representing an attempt to integrate structural interventions and HIV/AIDS prevention research. The study is a prospective, community randomised intervention trial among 8 villages designed to develop and test interventions addressing poverty, gender and inequalities. The interventions include microfinancing, gender and HIV training, and community mobilisation. It is funded by the Ford Foundation, Department for International Development (DFID), UK and Kaiser Family Foundation. Evaluation will include the impact of these interventions on a range of outcomes, including HIV incidence, at the individual, household and community level.
Women in conflict and post-conflict settings
Women in conflict situations frequently experience the worst that violence and gender inequality have to offer. Dr Agnès Binagwaho, Executive Secretary of the National AIDS Commission Control of Rwanda used the Rwandan experience of genocide and massive rape of Tutsi women as an example to illustrate the impact of such experience on women and society during and after the conflict period. Women were raped with the intent to infect them with HIV, and many women were left alone, after other family members were killed, and forced into high-risk behaviour for survival.
With 64% of the population living in poverty, 27% of children having lost one or both parents and destruction of much of the infrastructure, the national government launched a response with no prioritisation for women traumatised by the war, although the promotion of women is a primary goal of the Rwandan government. Community action was the real driver of the emergency response for women, organising as communities to provide support and care. At the moment, women survivors have access to care but not separate from the general populations; plans for special programmes designed for women survivors are being planned. Special programmes are necessary because of the double-stigma faced by these women: sexual violence and HIV/AIDS. Dr Binagwaho finished by listing special areas of research for women, including social research to increase women’s access to treatment and treatment success and behavioral research on acceptance of equality and rights for women before, during and after war. Community ownership and participation are essential cornerstones for these research activities.
Dr Kathryn Anastos, from the Bronx Women’s Interagency Study and a member of the Women’s Equity in Access to Care & Treatment (WE-ACTx) presented a framework for research including Rwandan women survivors of rape and genocide. The research framework is built on the maxim “treatment always trumps research in importance”. Dr Anastos stressed the need to seek and incorporate community and research participants’ opinions and the need to develop local infrastructure that will allow sharing and transfer of control to an in-country team. Dr Anastos has worked with the Rwandan Women’s Treatment Access Initiative, a collaboration of three partners: five survivor organisations, the Rwandan government through their Treatment and Research in AIDS Care (TRAC) programme within the Ministry of Health, and WE-ACTx. The goal is to provide comprehensive HIV care, including antiretrovirals and prophylaxis for opportunistic infections. The group expects to achieve this goal for 30,000 Rwandans. Plans are underway to establish the Rwandan Women’s Cohort Study, a collaboration between the three partners listed above and the Women’s Interagency HIV Study of the US. The collaborators will help define the research agenda, and will involve such issues as the influence of trauma on response to treatment, through biological mediators (eg cytokines), behavioral mediators (eg adherence) and bio-behavioral mediators (eg depression and post-traumatic stress syndrome).
The short panel discussion that followed the presentation of these three research themes included Judith Auerbach (amfAR), Anne-Christine D’Adesky (WEACTx), Catherine Hankins (UNAIDS), Sandra Lehrman (NIH/DAIDS), Glennis Mabuza (HIVSA), James Rooney (Gilead Sciences), and Dawn Smith (CDC) and was moderated by Veronica Miller (Forum for Collaborative HIV Research). Glennis Mabuza started the discussion by reiterating the positive effect of including women participants and communities in the planning of the research studies, and the importance of the studies such as the IMAGE study in her community in Soweto. The three research projects covered in this symposium – examples of three different approaches to addressing women’s needs – underlined the interdisciplinary and cross-disciplinary aspects of research in the context of women’s lives. More opportunities for performing research within such a framework are urgently needed.
The Planning Group for this symposium members were Judy Auerbach, Polly Clayden, Judy Currier, Anne-christine D’Adesky, Veronica Miller, Kathleen Squires and Fulvia Veronese. The speakers’ presentation slides are available on the Forum for Collaborative HIV Research’s website at:
Source: Forum News, Forum for Collaborative HIV Research; part of their report of their activities at the International AIDS Conference, which is also available at the same website.