58
been infected.4 Reduction of number of partners may not be an easy option for women for whom this is a part of their strategy for social and economic survival.6 Women’s subordinate position may not allow them to negotiate successfully the use of safe sex even when they perceive the risk correctly. 7,8 This process is also influenced by men’s attitudes and by notions of masculinity.7 Women’s knowledge, perceptions, choices, and ability to negotiate change with their partners should be understood in the context of the power balance in gender relationships and against its wider historical and cultural basis (Brooke GS, et al, unpublished). An effective contribution to facilitate change towards safer practices for women will need a better understanding of the conditions of transmission to all women, not just those in at-risk categories, of the social and cultural norms that shape women’s perception of risk, and of the constraints that women face to change their risk behaviour and to negotiate safer sex practices with their partners. This in turn will help to develop strategies to redress the lack of power of women to protect themselves against HIV infection and to negotiate safer sex with their partners.8 This lack of power is most often real, not merely perceived, as you suggest in your note. Oxfam, 274 Banbury Road, Oxford OX2 7DZ, UK, and London School of Hygiene and Tropical Medicine, London WC1
CLAUDIA GARCÍA MORENO LAURA C. RODRIGUES
1. Garda Moreno C. AIDS: women and not just transmitters. In: Wallace T, March C, eds. Changing perceptions: gender in development. Oxford: Oxfam, 1990. 2. Carovano K. More than mothers and whores: redefining the AIDS prevention needs of women. Int J Health Ser 1991; 21: 131-42. 3. Rodrigues LC, Garcia Moreno C HIV transmission to women in stable relationships. N Engl J Med 1991; 325: 966. 4. Lindam C, Allen S, Carael M, et al. Knowledge, attitudes, and perceived risk of AIDS among urban Rwandan women: relationship to HIV infection and behaviour change. AIDS 1991; 5: 993-1002. 5. Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plann 1989; 20: 297-307. 6. Bassett MT, Mhloyi M. Women and AIDS in Zimbabwe: the making of an epidemic. Int J Health Ser 1991; 21: 143-56. 7. Ankrah EM. AIDS and the social side of health. Soc Sci Med 1991; 32: 967-80. 8. Ulin PR. African women and AIDS: negotiating behavioural change. Soc Sci Med
1992; 34: 63-73.
p
SIR,-Professor Lecatsas and Professor Alexander’s (June 6, 1427) suggestion that the simultaneous appearance of HIV-1and
HIV-2 is evidence for the contamination of poliovirus vaccine being the origin of AIDS is flawed. They need to explain several points. How did two distantly related viruses contaminate the poliovaccine ? Why did this affect African countries more than others with much higher poliovaccine coverage? And why has long-term follow-up of people who received retrovirus-contaminated batches of poliovaccine failed to demonstrate ill health?l A simpler explanation for the simultaneous appearance of two dissimilar viruses lies in the main route of transmission. Since the end of colonialism there have been major social and economic changes in African countries.2 Those relevant to the HIV epidemic include rapid urbanisation across the continent, new road building improving communications, and the mass movement of people as a result of civil war and starvation. Urbanisation is likely to have brought HIV-1and HIV-2 into the cities and towns. Accompanying this urbanisation is greater sexual freedom from loss of tribal traditions, the migrant worker system which encourages multiple sexual partners and stimulates demand for prostitution, along with the growing poverty of many urban women increasing the numbers engaging in prostitution.2 These social factors lead to an increase in the number of new sexual partners, which allows any sexually transmitted disease, especially one with a long duration of infectivity to produce an epidemic. The developing road system allowed the virus to be moved across the continent. The high prevalence in truck drivers testifies to this potential. When people live in small social groups with little movement, as in rural villages, the spread of sexually transmitted diseases is much less than in large heterogeneous populations. HIV-1 has a low probability of infectivity, 0.1 to 0-2 for each relationship,3 and is dependent on the long duration of infectivity to maintain the infection. Major spread could only occur when the behaviour of the population changed, which happened with urbanisation. This theory explains how 2 dissimilar viruses, both sexually transmitted, have suddenly appeared and rapidly produced
major epidemics. Westbrook House, Sharrow Vale Road, Sheffield S11 8EU, UK
AIDS in India SIR,-It is gratifying to note, as your Round-the-World correspondent says (May 9, p 1162), that the Indian Government will be initiating a national control plan for AIDS with the monies given by the World Bank and the World Health Organisation. The plan is necessary because very few preventive measures are being undertaken, despite evidence that the infection is spreading. Although the initiative overcomes governmental reluctance to accept AIDS as a serious public health issue in India, there are several other difficulties that pose a greater challenge. Successful health education campaigns in developed countries may not work very well in India in view of low literacy levels, limited access to radio and television, and large rural populations. Added to these is the growing nationwide problem of alcohol consumption, which encourages casual sex. What is needed, therefore, is an active attempt to educate and modify behaviour through personal intervention. This has been successfully achieved in other communicable diseases and in maternal and child health. There has to be a national programme with community health workers whose primary aim is to inform people of the risks of AIDS and how these risks can be avoided. This may mean also a free distribution of condoms for safer sex which can also be an effective birth control method. Some use of existing communication channels needs to be undertaken simultaneously, aimed especially at urban populations. India needs a comprehensive and complex plan to prevent the spread of AIDS infection, and this may mean personal contact with 900 million people over some time. The current initiative can only be a starting point. Poole
Hospital, Nunthorpe, Middlesbrough, Cleveland TS7 ONJ, UK
Origins of HIV
R. S. RAMAIAH
KEITH NEAL
1. Beale AJ. Polio vaccines: time for a change in immunisation policy? Lancet 1990; 335: 839-42. 2. Larson A. Social context of human immunodeficiency virus transmission in Africa: historical and cultural bases of east and central African sexual relations. Rev Infect
Dis 1989; 2: 716-31. 3.
European Study Group on Heterosexual transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992; 304: 809-13.
Peripartum HIV seroconversion: a cautionary tale SIR,-A bottle-fed child aged 4 months was admitted to hospital with a provisional diagnosis of bronchiolitis. The child deteriorated and he required ventilation. On day 5 a tracheal aspirate was found to be positive for Pneumocystis carinii by a fluorescence antibody test and on day 6 a serum sample was reported positive for HIV-1/2 antibody. The child died on hospital day 27. The blood was sent to a reference laboratory for confirmatory tests for anti-HIV-1/2 and both gave low positive results. Immunoblot testing was indeterminate but there was reactivity to proteins p24, gp 120, and gp 160; the bands on the blot were definite but not strong, and could be consistent with low antibody level. The polymerase chain reaction (PCR) for HIV RNA was positive and p24 antigen was detected by enzyme immunoassay. During 1991, when this child was born, no HIV antibody positive newborn babies were found in Aberdeen by anonymous Guthrie card testing. The batch of Guthrie cards pertaining to this birth was retested by the department of child health, Yorkhill, Glasgow, and found to be HIV antibody negative. This was confirmed by a reference laboratory. The mother denied that she might be HIV positive. Later her general practitioner was able to discuss with her the death of her
been infected.4 Reduction of number of partners may not be an easy option for women for whom this is a part of their strategy for social and economic survival.6 Women’s subordinate position may not allow them to negotiate successfully the use of safe sex even when they perceive the risk correctly. 7,8 This process is also influenced by men’s attitudes and by notions of masculinity.7 Women’s knowledge, perceptions, choices, and ability to negotiate change with their partners should be understood in the context of the power balance in gender relationships and against its wider historical and cultural basis (Brooke GS, et al, unpublished). An effective contribution to facilitate change towards safer practices for women will need a better understanding of the conditions of transmission to all women, not just those in at-risk categories, of the social and cultural norms that shape women’s perception of risk, and of the constraints that women face to change their risk behaviour and to negotiate safer sex practices with their partners. This in turn will help to develop strategies to redress the lack of power of women to protect themselves against HIV infection and to negotiate safer sex with their partners.8 This lack of power is most often real, not merely perceived, as you suggest in your note. Oxfam, 274 Banbury Road, Oxford OX2 7DZ, UK, and London School of Hygiene and Tropical Medicine, London WC1
CLAUDIA GARCÍA MORENO LAURA C. RODRIGUES
1. Garda Moreno C. AIDS: women and not just transmitters. In: Wallace T, March C, eds. Changing perceptions: gender in development. Oxford: Oxfam, 1990. 2. Carovano K. More than mothers and whores: redefining the AIDS prevention needs of women. Int J Health Ser 1991; 21: 131-42. 3. Rodrigues LC, Garcia Moreno C HIV transmission to women in stable relationships. N Engl J Med 1991; 325: 966. 4. Lindam C, Allen S, Carael M, et al. Knowledge, attitudes, and perceived risk of AIDS among urban Rwandan women: relationship to HIV infection and behaviour change. AIDS 1991; 5: 993-1002. 5. Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plann 1989; 20: 297-307. 6. Bassett MT, Mhloyi M. Women and AIDS in Zimbabwe: the making of an epidemic. Int J Health Ser 1991; 21: 143-56. 7. Ankrah EM. AIDS and the social side of health. Soc Sci Med 1991; 32: 967-80. 8. Ulin PR. African women and AIDS: negotiating behavioural change. Soc Sci Med
1992; 34: 63-73.
p
SIR,-Professor Lecatsas and Professor Alexander’s (June 6, 1427) suggestion that the simultaneous appearance of HIV-1and
HIV-2 is evidence for the contamination of poliovirus vaccine being the origin of AIDS is flawed. They need to explain several points. How did two distantly related viruses contaminate the poliovaccine ? Why did this affect African countries more than others with much higher poliovaccine coverage? And why has long-term follow-up of people who received retrovirus-contaminated batches of poliovaccine failed to demonstrate ill health?l A simpler explanation for the simultaneous appearance of two dissimilar viruses lies in the main route of transmission. Since the end of colonialism there have been major social and economic changes in African countries.2 Those relevant to the HIV epidemic include rapid urbanisation across the continent, new road building improving communications, and the mass movement of people as a result of civil war and starvation. Urbanisation is likely to have brought HIV-1and HIV-2 into the cities and towns. Accompanying this urbanisation is greater sexual freedom from loss of tribal traditions, the migrant worker system which encourages multiple sexual partners and stimulates demand for prostitution, along with the growing poverty of many urban women increasing the numbers engaging in prostitution.2 These social factors lead to an increase in the number of new sexual partners, which allows any sexually transmitted disease, especially one with a long duration of infectivity to produce an epidemic. The developing road system allowed the virus to be moved across the continent. The high prevalence in truck drivers testifies to this potential. When people live in small social groups with little movement, as in rural villages, the spread of sexually transmitted diseases is much less than in large heterogeneous populations. HIV-1 has a low probability of infectivity, 0.1 to 0-2 for each relationship,3 and is dependent on the long duration of infectivity to maintain the infection. Major spread could only occur when the behaviour of the population changed, which happened with urbanisation. This theory explains how 2 dissimilar viruses, both sexually transmitted, have suddenly appeared and rapidly produced
major epidemics. Westbrook House, Sharrow Vale Road, Sheffield S11 8EU, UK
AIDS in India SIR,-It is gratifying to note, as your Round-the-World correspondent says (May 9, p 1162), that the Indian Government will be initiating a national control plan for AIDS with the monies given by the World Bank and the World Health Organisation. The plan is necessary because very few preventive measures are being undertaken, despite evidence that the infection is spreading. Although the initiative overcomes governmental reluctance to accept AIDS as a serious public health issue in India, there are several other difficulties that pose a greater challenge. Successful health education campaigns in developed countries may not work very well in India in view of low literacy levels, limited access to radio and television, and large rural populations. Added to these is the growing nationwide problem of alcohol consumption, which encourages casual sex. What is needed, therefore, is an active attempt to educate and modify behaviour through personal intervention. This has been successfully achieved in other communicable diseases and in maternal and child health. There has to be a national programme with community health workers whose primary aim is to inform people of the risks of AIDS and how these risks can be avoided. This may mean also a free distribution of condoms for safer sex which can also be an effective birth control method. Some use of existing communication channels needs to be undertaken simultaneously, aimed especially at urban populations. India needs a comprehensive and complex plan to prevent the spread of AIDS infection, and this may mean personal contact with 900 million people over some time. The current initiative can only be a starting point. Poole
Hospital, Nunthorpe, Middlesbrough, Cleveland TS7 ONJ, UK
Origins of HIV
R. S. RAMAIAH
KEITH NEAL
1. Beale AJ. Polio vaccines: time for a change in immunisation policy? Lancet 1990; 335: 839-42. 2. Larson A. Social context of human immunodeficiency virus transmission in Africa: historical and cultural bases of east and central African sexual relations. Rev Infect
Dis 1989; 2: 716-31. 3.
European Study Group on Heterosexual transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992; 304: 809-13.
Peripartum HIV seroconversion: a cautionary tale SIR,-A bottle-fed child aged 4 months was admitted to hospital with a provisional diagnosis of bronchiolitis. The child deteriorated and he required ventilation. On day 5 a tracheal aspirate was found to be positive for Pneumocystis carinii by a fluorescence antibody test and on day 6 a serum sample was reported positive for HIV-1/2 antibody. The child died on hospital day 27. The blood was sent to a reference laboratory for confirmatory tests for anti-HIV-1/2 and both gave low positive results. Immunoblot testing was indeterminate but there was reactivity to proteins p24, gp 120, and gp 160; the bands on the blot were definite but not strong, and could be consistent with low antibody level. The polymerase chain reaction (PCR) for HIV RNA was positive and p24 antigen was detected by enzyme immunoassay. During 1991, when this child was born, no HIV antibody positive newborn babies were found in Aberdeen by anonymous Guthrie card testing. The batch of Guthrie cards pertaining to this birth was retested by the department of child health, Yorkhill, Glasgow, and found to be HIV antibody negative. This was confirmed by a reference laboratory. The mother denied that she might be HIV positive. Later her general practitioner was able to discuss with her the death of her
