A research agenda for the 1990s / by Catherine A. Hankins

A research agenda for the 1 99Gs by Dr Catherine A. Hankins Epidemiologist at the Centre for AIDS Studies, Montreal General Hospital, Canada )though more than a third of all reported AIDS cases in the world are women , research efforts con- centrating on aspects of the AIDS epidemic that pertain particularly to women have been slow to materialise. So it is timely to document the most pressing research needs in the context of the worldwide effort to highlight the special problems that the epidemic poses for women. Awareness that women were being infected came belatedly in the industrialised countries, and coincided with the first confirmation of the heterosexual transmission of HN. From the beginning of the epidemic in some countries of Central and East Africa, men and women were affected in roughly equal numbers; neverthe- less, there was delay in recognising the importance of AIDS to women because of a host of medical and non-medical factors, not the least of which is the status of women in society. Worldwide, progress was hindered by this late recognition joined with discrimination, research problems specific to women, and lack of interest. In most countries, women are still less likely than men to be research subjects in clinical trials. The argument has been made that hormonal differences which could affect drug metabolism make studies in women irrelevant to the treatment of male patients, who constitute the majority of infected individuals in the industrial- ised world. Women also tend to be excluded from drug trials unless re- searchers can be convinced that they will faithfully practise contraception. This condition has not been imposed on infected men, even though experi- mental drugs may have effects on sperm production that could lead to congenital defects in their children. Mother to foetus An overriding concern for the foetus in many societies has meant that women who are already pregnant may be denied treatment for life- threatening illnesses. Could this be one reason why clinical trials of drugs which might reduce vertical transmis- sion from mother to foetus are only just completing the planning stages? Finally, there are in general fewer female than male researchers in all aspects of the HN /AIDS research effort, and since fewer women than men are infected in Western countries, scientists have been less attracted towards pursuing studies with rele- vance to women. The research areas that most deserve priority attention are sexual transmission, vertical transmission from mother to foetus, treatment and care, and the whole field of evaluation and prevention. It has been shown that biological factors, such as the presence of genital ulcers caused by herpes, syphilis or chancroid, and behavioural factors, such as unprotected anal intercourse, can increase the risk of sexual trans- mission of HN to women. But the interaction between various factors and their actual mechanisms of action are still not clear. The recently reported role of non-ulcerative infections such as chlamydia and gonorrhoea in facil- itating transmission of HN needs to be rapidly clarified, since control of these highly treatable diseases could be an effective and immediate method of limiting the speed of HN spread in many countries. A possible increased susceptibility to HN among women who are exposed to the virus while taking the oral contraceptive pill has placed this issue Health counselling for a drug user in Bangkok_ In most countries, women are still less likely than men to be included in clinical trials. ,.bff=:.l( .. ,_ .. :__ ~ ... ':': --.--... ·_--.: __ ;:;_;,~:,~ .• ;~;:;::"-~··" .111, "'~;! ·-> ~ _,., WHO/H. Anenden W ORLD HEALTH. November-December 1990 Grouping blood samples at the Kenya Blood Bank in Nairobi. high on the research agenda for women. Although the additional risk may be small, it is important that it be defined. Women want to be able to make informed decisions about whether to rely on condoms, the intra-uterine device or other contracep- tive methods for birth control in addi- tion to condoms for STD prevention. What little research has been con- ducted on the effect of spermicide use on HN transmission has produced contradictory results. Studies are urgently needed to determine whether spermicides may actually cause irrita- tion on the lining of the vagina which could facilitate entry of the virus into the body. The nature of male resistance to using condoms also requires close investigation. Research to discover methods of reducing the rate of transmission from mother to infant is itself in its infancy; much remains to be learned both about the effects of pregnancy on HN disease and the effects of HN infection on pregnancy. A greater effort in this field to describe the determinants of HN transmission during pregnancy and at childbirth may show up medical and behavioural ways in which vertical transmission can be minimised. Vttal questions Does pregnancy precipitate a deter- ioration in the mother's health or does it protect her from clinical progression of her HN disease? Is there less chance of transmission from mother to foetus if the mother has been infected for a shorter period of time? If yes, would it not be preferable for women who want a baby to become pregnant earlier rather than later in their infec- tion? Sufficient rigorous studies have yet to be conducted that will give a clear answer to these important questions. So far, all the cases of HN transmis- sion attributed to breastfeeding have occurred among mother-infant pairs where the mother was not infected at the time of her pregnancy or childbirth. It is vital to determine whether breastfeeding poses an additional risk for the uninfected infant who has received maternal antibodies from his or her infected mother during preg- nancy. Women need to know whether they can breastfeed safely. As regards treatment and care, the natural. history of HIV infection in women has not been well studied. Therefore, it is still not clear whether 25 A research agenda for the 1990s women experience shorter survival times than men. Little attention has been paid to the unique features of HN disease in women, and in particu- lar to gynaecological complications such as vulvo-vaginal candidiasis, also known as yeast infection. Cohort studies in which groups of infected women are followed over time would help describe the clinical course of HN in women. Hormonal influences on drug metabolism too have not yet been clearly described. Little clinical research which might benefit women subjects is currently being carried out in Africa, largely because of the high cost and, as a result, few treatments are available for more than simple symptomatic relief. Clinical trials of appropriate medical interventions would serve the critical dual purpose of advancing scientific knowledge directly relevant to a developing country setting while pro- viding care which otherwise would be unavailable. In most societies, women undertake the lion's share of both professional and domestic care-giving. They must attend to the immediate needs of infected partners, of their infected and non-infected children, and of depen- dant elderly family members, in spite of the ravages of their own HN infection. 26 Studies are urgently needed that can show the effectiveness, both in developing and in developed coun- tries, of care techniques to ease discomfort and provide symptomatic relief for non-curable complications. Research could also show how medical services, traditional healers, and home and community supports could interact in different cultural and economic settings so as to share more effectively the burden of care-giving. Safer sex Prevention research is essential to evaluate the effectiveness of behav- ioural, biological, administrative and other strategies in preventing HN transmission . Programmes aimed specifically at women need to be scientifically assessed to determine the factors affecting safer sex behaviour in women. How can interventions for drug dependency be improved? How may prostitutes be assisted to protect themselves from HN transmission, or to obtain support if they desire to leave the sex industry? Vaccine development is of crucial interest to women for the prevention of both sexual transmission and verti- cal transmission from mother to child. Studies of vaccine efficacy involving women will most likely be conducted Rapt attention at a lecture in Mexico City. "Women want to be able to make informed decisions about methods for birth control in addition to condoms for SID prevention." in African and Caribbean countries with high rates of these forms of transmission. Research in the 1990s must also focus on reducing blood transfusions associated with childbirth and decreasing the use of inade- quately sterilised injection equipment. Programmes to reduce nutritionally- induced iron deficiency or to combat chronic malarial infection can help to cut down on blood transfusions, with their inherent risk of HN infection. Such studies are particularly relevant to women in non-industrialised countries. The focus that the 1990 World AIDS Day is putting on women allows researchers, educators, patients, care- givers and funding agencies alike to reflect on the urgent research priorities that will affect most women. Positive action is essential now to reduce the current shortfall in research and to stimulate research efforts that will have immediate and long-term application to women. • WORLD HEALTH. November-December 1990