The year was 1987. AL-721 (the egg yolk mixture from Israel) and dextran sulfate (a heparin derivative usually scored from Japan) were the "cures du jour." AZT was brand new, as much of the world mistrusted Burroughs-Wellcome's alleged profiteering. $10,000 a year for a set of pills which had to be taken every four hours, including in the middle of the night, and which necessitated blood transfusions for some.
The AIDS Conference that year was held in Washington, D.C. The attendees and speakers were often white men in suits, one of them being guest speaker Vice President George Bush. Speaking for an administration whose leader of six-plus years had yet to mention the "A" word in a national speech and whose Congress was gearing up to ban infected persons from entering its "golden shores," Bush came out to address the assemblage. As he approached the podium and began to speak, there was enough wrath to meet his initial words with a chorus of "Shame!" and other hissing gestures. He seemed surprised.
In what has to be one of the most memorable moments of any AIDS meeting in history, he turned his face away for a moment, looked behind him, and evidently didn't realize his microphone would still pick up his next words of whispered explanation and/or self-consolation, and broadcast to thousands: "Must be a gay group..."
Also at that meeting, in the exhibit area, along with booths peddling pentamidine and ELISA test reagents, a huge map of the United States hung on a wall behind a series of tables. The map highlighted the names and locations of cities with allegedly large homosexual populations (did they use the Bob Damron guide?, I wondered). I don't remember the name of this right-wing fundamentalist group -- they were from a Great Plains state, and their name did not mention the word "gay" or "AIDS" but over the map were suspended words which might as well have been decorated with swastikas:
THE PROBLEM: AIDS
THE SOLUTION: BANISH ALL HOMOSEXUALS
More amazing to me than the fact that the exhibitors were allowed to be in the conference venue, was that except for one brave man, soon-to-be-carted-off-by-the-police after he tried to turn over their exhibit table, everyone just let it be. (To this day, I feel a personal sense of shame for being among the thousands who didn't "act up." After all, ACT UP was just forming.)
The cover of California magazine that October featured "Patient Zero," flight attendant Gaetan Dugas, who allegedly had had sexual relations with a double-digit percentage of the first reported AIDS cases. Some blamed him, but you really had quite a choice on where to place blame in 1987: Green monkeys. Haitians. Poppers. African swine fever virus.
Not until 1989 did a person with HIV address the International AIDS Conference; not until 1991 did women and their advocates truly make a showing.
The Geneva meeting appeared to me to be so filled with studies, conjectures and statistics about women, that it would be hard for even the staunchest advocates to complain about a lack of pertinent information.
Throughout the conference reverberated the progress which has been made in reducing vertical transmission in the mere four years since the announcement of the findings of ACTG 076 -- in which AZT-treated pregnant women reduced HIV transmission rates to their offspring by around 70 percent.
"Perinatal HIV infection is now a preventable disease," noted Dr. Lynne Mofenson of the National Institutes of Health.
The major boost to this -- "Bridging the Gap" to the developing world -- was perhaps made earlier this year with the announcement of the Thai study involving a two-part course of AZT -- rather than the three-part course commonly used in the U.S. and other developed nations (Abstract 33163). It was shown that a pregnant woman starting AZT as late as week 36 (approaching term), with the drug being administered orally through the rest of the pregnancy, would decrease the chance of transmitting HIV to the baby by around 50 percent. Cost: $50.
This fits with results of years of research which seem to demonstrate that while transmission may occur anytime from early in the pregnancy through postpartum (via breastfeeding), a significant proportion of it occurs during delivery, the so-called intrapartum period.
In the three-part program, AZT is given to the pregnant woman orally after 14 weeks, then intravenously during labor and delivery, and then orally to the newborn for the first weeks of life. This program has been shown to reduce fetal transmission by around 70 percent. Cost: $800.
Another trial from a developing nation (already published last year in the British Medical Journal) involved the use of chlorhexidine -- an agent to cleanse the birth canal -- in comparison to a control group which did not have such. The Malawian researchers found no statistically significant difference in rates of HIV transmission, but the infants in the chlorhexidine group had significantly lower morbidity, fewer subsequent infections and fewer hospitalizations. Even if this is not decreasing HIV transmission, its antimicrobial effect may reduce other neonatal problems.
The Swiss HIV Cohort, which has been making itself known for a number of key studies (even prior to it being the host country of this year's Conference), reported on pregnancy outcomes in 37 women who were treated with antiviral therapy during pregnancy (Abstract LB.10). The official U.S. recommendation still calls for AZT monotherapy, even though most pregnant women are being offered at least two nucleoside analogs.
In this group, 16 of the women (43 percent) had protease inhibitor therapy as well. As many clinicians would be reluctant to prescribe a class of drugs about which so little is known during pregnancy, it should be noted that a majority of them became pregnant while already taking protease inhibitors.
In this group, which included women on each of the four approved protease inhibitors, no unexpected or life-threatening events happened to the mothers.
However, in 30 of the 37 who had already delivered at the time of the conference (this was presented at a session on the last day of the conference), there were three adverse events in the newborns.
First, 10 of the 30 were premature, yielding a rate of 33 percent (the usual rate of prematurity in HIV-positive women delivering is under 20 percent). Two of the infants had a cerebral hemorrhage (blood in the brain), one of them a term infant: a highly unusual occurrence. And lastly, one infant was born with a serious problem known as biliary atresia, the abnormal and inadequate development of the bile ducts inside or outside the liver.
Indeed, what is not known is whether or not these are related to the use of the antiviral medication. In the U.S., there is an HIV-pregnancy database, and providers are urged to call (800) 722-9292, Ext. 38465 to register women.
The current state of therapy, as well described at the conference by Dr. Kathleen Squires of the University of Alabama, is to be vigorous about treating the maternal HIV infection, as long as nothing is being done which is known to be harmful to the fetus.
"Say It! Women Get AIDS! ACT UP!" was a slogan on an ACT UP T-shirt years ago.
In Geneva this year, at least a couple of poster presentations involved lesbians, a group that for years was under-represented in HIV-related probes and studies.
A survey from the University of Illinois and New Orleans (Abstract 23428) indicated that lesbians aren't necessarily engaging in risk reduction activities. Of 82 lesbians who had reported vaginal sex with a partner in the prior six months, only four had used a barrier. Of 18 who had had vaginal sex with a man in that interval, only one-third used a condom.
A study comparing HIV in the cervicovaginal tract with that in the plasma found significant differences in viral composition, resistance patterns and actual levels (Abstract 33279).
Not too many AIDS Conferences ago, activists would raise their hands and ask study presenters, "Why were there no women in your study?" Well, here's one for which someone might have asked, "Where are the men?"
"Women First" is the clever name given to this important study of quadruple therapy (Abstract 12305) in women who had never taken protease inhibitors before (and have had less than one month exposure to d4T and/or 3TC). The 46 women recruited were randomized to receive standard doses of d4T and 3TC and then two protease inhibitors, nelfinavir (Viracept) and saquinavir-hard gel capsules (Invirase), either twice daily or three times daily.
The study showed that the BID and TID regimens were equally potent in suppressing viral load. Also, those patients with initial viral loads greater than 100,000 copies/mL were more likely to have detectable virus in the cervicovaginal lavage.