The International Epidemiologist
A Talk With Zena Stein
For many years in the early part of the U.S. epidemic, there was a general denial that women were at risk for getting AIDS from sex. Even when it was clear that women were being infected, the risk was not taken seriously. Now, half of new HIV infections occur in women. How did you, as an epidemiologist, go about understanding what you were seeing when this new disease first appeared?
When I began my very first work with AIDS it was still called "Gay-Related Immune Deficiency." The cases were mostly in gay men, but we knew it was blood borne because hemophiliacs got it from blood transfusions, and some patients who got it were injection drug users. And we began to ask, well, if gay men are getting it through sex, then why wouldn't women get it too? For a long time people just kept saying, "Women don't get it." I started talking with a colleague -- and this is before we knew it was a virus causing the disease -- and we said, "Women must be getting it. And there must be some reason why women get it." We did some very exciting work going around to different scenes where people were having sex, to see if the women knew anything about these men they were having sex with. Some of these were men who usually had sex with other men. And it made sense. Think of the social circumstances: gay men cross over into women's society. But people didn't really believe us. It took time and effort and continually saying "Well, women do get it this way." My proposal to the NIH for further study was turned down because "it wasn't a woman's disease."
How did looking at the epidemiology given your previous work on pregnancy help you understand what was happening with infants born to HIV-positive women?
The transmission of disease from women to children has always been central to family health and reproduction. I think what especially intrigued me was when I realized that transmission only occurred in one of three children. So, why doesn't it always occur? My colleague and I tried to think of ways we could come closer to understanding in which babies does transmission occur, and why? And we thought of looking at planned C-sections, to see if the baby wouldn't get infected through the canal and if we could reduce transmission to babies. Another study about twins came out around the same time, where the first twin didn't get infected very often, but the second twin down the birth canal was more often infected. So we realized that the environment of the birth canal must be a place where the transmission takes place. Which indeed was true, and is why most of our mother to child prevention protocols say, as long as you get to the woman before she goes into labor, transmission rates go down. And now we also know, nevirapine given before labor lowers the viral load and reduces transmission by quite a lot. Knowing the circumstances of the birth was the key.
When was it that you really began to see the need for a microbicide that women could have some control over?
When I began to think about AIDS in Africa, people kept talking about male condoms. I talked a lot with a friend and colleague who is a sexologist about how, before we had the hormones to prevent pregnancy, we had condoms -- the male condom, or a woman could use a diaphragm. Neither of these were 100 percent effective, but they were reasonably effective. The male condom goes back in history much farther than the diaphragm, but once the diaphragm started emerging in the 1920s, the responsibility started shifting from men and their condoms to the woman to use the diaphragm. Then in the 1960s it moved completely to the woman with "the pill," which was very effective for contraception, so that if something happened the man could say, "Well, the girl didn't take the pill." The threat of pregnancy was largely eliminated by the pill but now the onus was on the woman. And now we have emergency contraception, which enables you to mess up occasionally and we have legalized abortion too, if you want it. These are big advances for women, to have this control over pregnancy. But they don't protect against HIV.
When I first started writing about microbicides, I used to say we needed a "woman-controlled" method and argued that it could or should be a secret from the man -- clandestine. It's been a long time since then and I've come to understand that that's really not quite right. First of all it depends on the relationship. In many relationships, women don't want to hide anything from their partner because if they do, they upset the relationship. It's better to discuss it. If you can discuss it, you could argue, then he can use a condom. True. If you can discuss it, he might be quite relieved to know he doesn't have to worry about a pregnancy. But if he discovers that you're doing something and not telling him, or if he expects children and won't accept contraception, that's very tricky. If he wants her to get pregnant, he may start to wonder if there's something wrong with her when she doesn't get pregnant. And different groups of women use and need different strategies for getting around this.
Another problem is that the microbicide must be clandestine at the time of sex or before, because the maximum period of time it can be applied before sex is very important for efficacy. Even so, microbicides are not going to be as good as condoms -- everybody knows that -- still they can go mostly unnoticed. But I don't think you can or should betray your relationship with these clever, funny devices.
What specific problems do you think activists should be focusing on?
Women in certain parts of Africa who already have two or three children -- they're not always the ones getting infected. But if a woman is 17 or 18, she may go in to the clinic for a few years of contraception and use a barrier. But at some stage, she will want to get pregnant, and I think nobody's dealing with that.
And then, there's the sweeping problems no one wants to address: the economic and political realities that are driving transmission. For example, we see it quite plainly in South Africa among men -- migrant gold miners from the rural areas -- who consort with sex workers and are a source of STIs (sexually transmitted infections). And before HIV, it was syphilis. They'd go away for work and then they'd go back home and their wives often got infections of the cervix. There have always been jokes about commercial travelers -- in Sub-Saharan Africa it's truck drivers all along the regular routes they travel -- and these things are true: when men are separated from their families, they get more STIs. The trucks come down and the sex workers are around where the drivers stop. So, the workers in occupations involving migrant laborers or work far from home need special education, because the breaking up of families is an integral part of such industries and economies. And it's less the sex workers than the truck drivers who should be the subject of special education. All the studies suggest that sex workers won't push for condom use by their driver or miner clients because that reduces what the client is willing to pay.
What do you see as some of the main stumbling blocks for microbicides becoming responsive to the needs of different women?
Well, one thing is the way they're planning to deliver it -- by squeezing it in. We've got to get new technology there. There's a ring you can put against your cervix that's currently being used for contraception. Now, if the ring can be made to carry a microbicide, and if women choose to use the ring, then you won't have this bother of putting the stuff in -- it will already be there. If the microbicide just sits in this little container by the bed, then you won't have proof of concept from your clinical trial. If we find that women aren't really using the microbicide during sex, then this problem of improving the method of delivery has got to be taken seriously.
Another important thing to many women is whether they can become pregnant. For example, Carraguard may not be contraceptive; but some of the others will likely be. For some women, and for some societies, it's extremely important to be fertile. That will be the next problem, assuming we observe some efficacy in the trials: after the ten years it takes to get a microbicide, at the end we won't know whether it's contraceptive or not. We've a long way to go before we have a microbicide that women who want at least one or two children are going to use.
I don't think the microbicides delivered as we are doing it now in the trials are going to be terribly effective. They are possibly only about forty or fifty percent effective, but nobody knows because we haven't got anything to compare them with. The only comparison we have is with 95 percent consistency from the direct use of a condom. So I am in favor of not only of having a microbicide approved but of also having the female condom, and one of these cervical devices. We need an array of options for a woman.
There is no simple path to achieving more effective methods for woman-initiated STD/HIV risk reduction. Women who desire both pregnancy and protection from HIV/STDs may not have a safe and effective microbicide available in the foreseeable future.
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.