Commentary Sexual Health

Learning and Teaching About HIV and AIDS: Video Resources for World AIDS Day

Bianca I. Laureano

A list of resources for educators and parents for World AIDS Day.

December 1st is World AIDS Day. There are many resources and media educators can use in the classroom to draw attention to and teach about HIV and AIDS. Often I’ve noticed that educators use forms of media and activities that honor those who have died of complications of AIDS, focus on rates of HIV infection worldwide, and are only discussed for one day or week. Forgotten are those who are living positive with HIV, especially youth, honest discussions about transmission and treatment of HIV and AIDS, and on how the ideas of young people can be used to raise awareness and educate others in an inter-generational way.

In the past I’ve shared some resources I’ve found useful for educational and community space for World AIDS Day and for discussions about living positive and remaining HIV negative. These include suggestions for National Women and Girls HIV Awareness Day March 10th, how I approach and discuss conspiracy theories around HIV with students who bring them up, the myths and messages youth have around HIV and AIDS,  interview with Miss Kings County 2011 whose platform was “de-stigmatizing getting tested for HIV,” a history of HIV and AIDS media messages, and examples of how I teach and discuss HIV and AIDS in a human sexuality class.

One of the first things I hope we as educators remember is that although there is one day worldwide we focus on HIV and AIDS; these are conversations that must occur year round. The most comprehensive film about the history of HIV and AIDS in the US and internationally is the PBS Frontline documentary Age of AIDS. The full program is online  and over 3 hours long. Often I have students watch the first hour and a half at home as homework and then watch the last hour to get an idea of how the views of HIV and AIDS emerged and have shifted today. Below are a few sources of media that may be useful for educators and those working with youth or planning interactive programs for HIV and AIDS in general and for World AIDS Day.

“I’m Positive” Documentary

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This year MTV has partnered with The Kaiser Family Foundation, Octagon Entertainment, and DrDrew Productions to present the documentary “I’m Positive” focusing on three young people living positive and will air on World AIDS Day. If the communities you are working with have access to cable or the internet, it may be a good idea to mention this documentary and ask them to watch. I’m not a huge fan of Dr. Drew’s work with youth, but believe there may be a lot of useful discussions we can have with viewers pre-and post-watching the documentary. I have no doubt that MTV will have this documentary on their website within 24 hours of it being aired and that it will air more than once. 

TheSEROProject

Sero is a non-profit human rights organization that centers people living positive. Their mission includes “promoting the empowerment of people with HIV, combating HIV-related stigma and advocating for sound public health and HIV prevention policies based on science and epidemiology rather than ignorance and fear.  Sero is particularly focused on ending inappropriate criminal prosecutions of people with HIV for non-disclosure of their HIV status, potential or perceived HIV exposure or HIV transmission.” 

Sero has created an online library of video testimonies of people living positive. These videos go well with The Body’s publication by writer Dave R. “Crime and Punishment: An International HIV Disclosure Dilemma.”  Dave R. follows and reports on some of the cases occurring worldwide around HIV disclosure. Below is the story of Monique Moree, an Army veteran who was prosecuted for non-disclosure. 

TeachAIDS HIV/AIDS Prevention Tutorial 

TeachAIDS is a project at Stanford University focusing on creating interactive approaches to educating folks on HIV and AIDS. The have a strong library of videos on their YouTube channel with videos on Mandarin,  Swahili,  Kinyarwada,  Hindi,  Telugu, and Spanish. Below is a cartoon style clip featuring Southeast Asian communities. The video also has built in subtitles in English. I appreciate their representations, especially of the white blood cells as soldiers. This is one way I explain to youth what white blood cells do and how they keep us healthy. If you only have a hour long session and want to get good information into your time with students, this video covers all of the HIV 101 needs.

BrainPop

I’m one of those educators who believes it’s important to discuss HIV and other aspects of our bodies and sexuality with youth in age appropriate and honest ways throughout our lives. As a result, I loved when the online teaching site BrainPop created a short video for HIV. They have a full space devoted to health topics and one of their free videos each year for World AIDS Day is on HIV. They also feature BrainPop Jr. for grades K-3 and BrainPop en español. If your school or space does not have the funds to subscribe to BrainPop they offer a free 3 day trial offer where you an explore the site and watch the films and take the short quizzes offered.  

Apps

Finally, encouraging youth to find locations to get tested now has an app! The U.S. Centers for Disease Control and Prevention has created the HIV/AIDS Prevention & Service Provider Locator which can be used as an app or on other mobile devices. I admit I was very surprised when I used the locator for my area and discovered there were NO testing locations in my community, which is also the community where I teach. Although there were several testing areas in other communities near my neighborhood, they were all over several miles away. I wonder what does this mean for the youth and students I work with on a daily basis who want to know their HIV status and need testing services.

To remind those of us who remember a time when HIV and AIDS were not widely known about that we are living in the future, researchers re also looking to create an app that can test for HIV via a cell phone. These approaches to using media, popular culture, technology, and medicine to test for HIV can have an impact on youth today. I’m sure they would have a lot to say about if this would work for informing partners, communicating with a partner, and issues of hacking.  

What are some of the sources you use in the classroom or with your community? If you’ve used any of these what have been the reactions? Here’s to supporting one another as educators. If your students and faculty haven’t told you that you are appreciated I want you to know I appreciate all the work and education that is being done worldwide.

Commentary Contraception

Advocates Call for Full Funding of Research on HIV and Contraception

Lillian Mworeko & Emily Bass

For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, a shortage of funding for the ECHO (Evidence for Contraceptive Options and HIV Outcomes) trial is an unacceptable development.

A clinical trial known as Evidence for Contraceptive Options and HIV Outcomes (ECHO)—originally designed to answer important questions about possible connections between risk of HIV infection and the use of non-barrier hormonal contraceptives—now hangs in the balance because of a funding shortfall. For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, this is an unacceptable development.

Women make up more than half of all people living with HIV worldwide, and they continue to bear the burden of new infections. Incidence rates vary by age and country, but remain unacceptably high in the context of comprehensive, state of the art prevention services. (As one example, in the VOICE trial of women’s HIV prevention options, overall incidence was nearly 6 percent.) HIV incidence rates are particularly high in adolescent girls and young women, and globally HIV is the leading cause of death of women of reproductive age. The same women who are most at risk of HIV are also in need of a variety of reliable methods of contraception—a glaringly unmet need in sub-Saharan Africa, where fewer than 20 percent of women use a modern contraceptive method.

For those women in sub-Saharan Africa who do have access to contraception, the majority use a hormonal method (an injectable or the oral contraceptive pill). Of these women, 60 percent use a long-acting injectable such as Depo or, less frequently, NET-EN. This prevalence of these methods does not accurately reflect women’s preference since in many settings, Depo is one of a limited number of options for women—and often the only long-acting, discrete method (versus a daily contraceptive pill). Expanding the range of available choices is another key policy and advocacy priority, in sub-Saharan Africa and around the world, including in the United States.

Contraception not only allows women to determine when and how often they become pregnant, it also saves their lives. Risk of maternal morbidity and mortality—already unacceptably high in many parts of the world—rises even more in the context of unplanned pregnancies. Lack of access to effective contraception is a health and human rights issue that cannot be ignored.

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At the same time, there are persistent questions about whether some contraceptive methods, particularly long-acting injectables like Depo, increase women’s risk of acquiring HIV. These questions arise from observational data. Some studies suggest that Depo does increase risk, while others do not. This is precisely the question that the ECHO trial is designed to answer.

According to the ECHO trial team, which has briefed civil society, it would cost roughly $60 million to conduct the ECHO trial—clearly a minimal investment when compared to the economic, social, and public health costs of HIV and AIDS, unplanned pregnancies, and maternal death and illness across sub-Saharan Africa. In fact, the ECHO trial seeks to answer a question raised 25 years ago: Do contraceptive methods, particularly hormonal contraceptive methods, increase women’s risk of HIV acquisition? The answer to this question is long overdue, and the lack of investment in such research reflects a lack of strategic and financial priority for a critical women’s health and rights question.

In discussing the trial, and other approaches to the current uncertainty, stakeholders have asked why the data are mixed, and whether it’s possible to gain clarity with the information available and/or with basic science studies. The main limitation of all of the existing data on both injectables and pills and potential HIV risk is that they come from observational trials that were not designed to answer the question directly. Confounding factors cannot be controlled for, and many trials rely on women’s self report about the method they were using. There simply aren’t enough women in sub-Saharan Africa using other strategies, like the implant or the intrauterine device, to gather even observational data. The existing information is, therefore, difficult to interpret, and leave unanswered critical questions that affect the lives and health of women who have urgent needs to both space or limit births and to protect themselves from HIV. The ECHO trial is designed to help answer these questions directly for Depo, the implant (Jadelle), and the copper intrauterine device—methods about which there are even less data. It has the potential to provide more definitive, actionable information than basic science research.

The ECHO trial is the type of research we have been waiting for, with great anticipation, since a 2012 World Health Organization (WHO) review of the existing data on hormonal contraceptives and HIV risk. In this review and in an update in July 2014, research is a clear priority. The document states, “WHO strongly supports the need for further research to identify definitive answers to these issues.”

ECHO was proposed to meet this identified need. It is a randomized clinical trial that would look at whether the three options—Depo, Jadelle, and the copper intrauterine device—affect HIV-negative women’s risk of acquiring HIV.

Advocates for HIV-positive women, HIV prevention advocates, and sexual and reproductive health advocates have been following this issue closely. We are united in the conviction that women should be fully informed in their contraceptive choices and that we should not have to choose between HIV prevention and safe and effective contraception. We are also united in the need to broaden the range of contraceptive options available and accessible to all women—in the context of complete data about their risks and benefits.

The concerns related to HIV risk have to be considered in the context of the health risks of pregnancy, particularly unintended pregnancies. Epidemiologists have calculated the new HIV acquisitions that might be attributable to Depo, in the event that it does increase risk, and the rates of maternal deaths and live births that would occur if Depo were to be withdrawn, without an immediately acceptable and accessible replacement. In both instances, the greatest impact on women is in east and southern Africa.

Given the level of maternal death and illness, not to mention other public health outcomes of unintended pregnanciesy, an increase in risk of HIV acquisition by users of Depo must be weighed against the risks associated with unintended pregnancies. But context does not mean conflict—and the urgent need for a mix of effective contraceptive methods does not outweigh the need for clarity about how methods affect women’s risk of HIV acquisition. No one wants to swap illness and death associated with HIV acquisition for pregnancy-related morbidity and mortality.

And, indeed, no one is advocating for Depo to be removed without providing affordable, accessible alternative contraceptives. But the status quo cannot stand because of the challenges ahead. Current WHO guidance on Depo states that “women at high risk of HIV infection should be informed that progestogen-only contraceptives may or may not increase their risk of HIV infection.”

Not only is the message confusing, but it is also incredibly challenging for those working in public health clinics to communicate. Without the ECHO trial, this confusing message will continue being given to women currently using or initiating Depo—if they receive any message at all. Even as other methods, such as the contraceptive implant, gain popularity in some regions, some women will still only have access to Depo and they will still be told “this might increase your risk; it might not”—unless a trial like ECHO takes place.

Unfortunately, the international funding community has not adequately committed to this research. Even before the current ECHO protocol was put on hold, it had already been scaled back once due to budget concerns. This trial design should be driven by scientific questions and women’s needs, not funding.

We call on the donors to ensure the trial is fully funded without additional budget cuts or delays. We call on funders who have stepped up to date, including the Bill & Melinda Gates Foundation, USAID, the South African government, the South African Medical Research Council, the Wellcome Trust, and the UK Medical Research Council to maintain and/or expand on existing funding commitments. We challenge the U.S. National Institutes of Health and the European & Developing Countries Clinical Trial Partnership to confirm their partnership with and support for this research. And we urge these funders to work together to undertake vigorous advocacy that bridges the HIV and contraceptive research agendas. Each of these organizations have spoken about the need to promote women’s health and now they must invest in doing so. The amount of funding needed is minimal compared to investments in many other HIV prevention trials. These price tags reflect vastly different research questions and infrastructure requirements—however the point remains that this is a relatively small investment to answer a question of enormous importance.

Some funders, scientists, and advocates have raised issues about whether the trial is necessary or feasible. One argument is that the world can go ahead and increase method mix, moving away from Depo and toward other methods, without the ECHO trial. This would mean expanding access to other hormonal methods without any additional information about their relationship to HIV. The question about whether the trial is feasible—whether women will enroll, accept randomization, remain on methods, and so on—is valid, and can only be answered by attempting the trial. ECHO investigators say the research would be implemented with monitoring that would gauge feasibility in real time—allowing the trial to be stopped or altered if it was necessary.

Although concerns about the trial are fair, a $60 million investment in this set of questions is one of the best research investments that could be made in reproductive health and rights in the context of women and HIV today. As women in all our diversity, this advocacy—and the clarity it can engender about our contraceptive choices—is long overdue. Women at risk of HIV deserve to know whether their choice of contraception affects their chances of acquiring HIV. Now is no time to turn back.

News Sexual Health

Another Case Raises Hopes About Early Treatment for HIV-Positive Babies

Martha Kempner

Doctors in California believe that they have cleared HIV from the blood of a nine-month-old who seems to have been born with the virus. Though they can't call it a "cure" or even say she is in remission because she continues to take medication, her doctors believe she has "sero-reverted to HIV-negative."

Last year at this time, doctors in Mississippi announced that they had cleared a two-year-old girl born with HIV of the virus by giving her high doses of anti-retroviral drugs within 30 hours of her birth. Now, details of another case—this time in Long Beach, California—have been released at an AIDS conference; doctors say that once again HIV has become undetectable in the blood of a small child. Doctors in the new case followed the protocol set in Mississippi, and many experts are finding the results to be promising.

Anti-retroviral therapy (ART) can suppress HIV to the point that the virus becomes virtually undetectable in a person’s blood. This treatment allows people with HIV to stay healthy for years and even decades, but it cannot be considered a cure because once a person stops taking his or her medications the virus quickly reappears in their blood. Scientist have discovered what they call “HIV reservoirs,” cells that hold the genetic code of HIV but are dormant and invisible to the immune system and drug regimes. These cells hide in the brain, bone marrow, genital tract, and other places in the body. If individuals stop taking their drug cocktails, the reservoirs are likely to become active and HIV can start replicating itself again.

When the Mississippi baby stopped taking her medication, however, the virus did not return. The infant’s mother received no prenatal care and did not know that she herself was infected when she had the baby. Doctors tested the baby’s blood after delivery and declared that she was HIV-positive. They put the baby on high doses of anti-retroviral drugs within 30 hours of her birth and she remained on this type of medication for about 18 months. Had the baby continued to be brought to her appointments, doctors would have kept her on the medication indefinitely, but she was lost to the system for almost six months and was not given her drugs during that time. Doctors were shocked when she returned and they realized that despite this absence of treatment she was for all intents and purposes free of the virus. They speculate that efforts to eradicate HIV from the body, which have never truly been successful in adults, may be possible in infants because treatment begins before HIV reservoirs are built. The Mississippi infant, now three years old, remains virus-free despite being off of all medications. Some experts question whether she was ever HIV-positive or if, instead, “the positive tests simply registered small amounts of the virus that had spilled over from the mother’s bloodstream during delivery.” Because they did not expect her to become a breakthrough case, her physicians did not save her blood and no new testing can be done, but they are convinced she was HIV-positive.

The Long Beach case provides some confirmation that this approach works, although the child, who is now nine months old, remains on her medications. The infant’s mother arrived at Miller Children’s Hospital in labor. She was mentally ill and had advanced AIDS, and though she had been given a prescription for anti-retroviral drugs that could have prevented her from infecting her fetus, she had not taken them. Physicians tested the child for HIV four hours after she was born, and both RNA and DNA for the virus were present in her spinal fluid and blood. They are convinced she was truly infected.

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Following the Mississippi protocol, doctors gave the baby high doses of three drugs used to suppress the virus immediately after birth. They then tested her blood extensively and found that the virus began to disappear after six days and was completely gone by day 11. This baby cannot be considered “cured” or even in remission, however, because she continues to take her medications. Despite the potential success in these two cases, it would be unethical to take the child off the drugs in order to see if HIV comes back. Her physicians say that if she remains virus-free as of the age of two, they might consider taking her off the drugs for a period of time to see what happens. In the meantime, they have run the most sensitive blood tests available and can find no virus that is capable of replicating. Her lead physician told the New York Times that she describes the baby as “having sero-reverted to HIV-negative.”

The truth is that science has in many ways solved the problem of mother-to-child transmission of HIV. Had these mothers received adequate prenatal care (and taken their prescribed drug regimens), HIV infection in their infants could have been prevented and there would have never been a need to eradicate their bodies of the virus. In the United States, most pregnant women get the medication they need, but worldwide the number is only at 60 percent. These two cases, therefore, potentially provide a roadmap for “curing” babies who are born HIV-positive.

New studies are being planned to further test this concept. For example, a clinical trial set to begin soon will put up to 60 babies born HIV-positive on a drug regimen within 48 hours of birth to see if they, too, become virus-free. Dr. Anthony S. Fuaci, executive director of the National Institute for Allergy and Infectious Disease, told the New York Times that these results are important. “This could lead to major changes for two reasons,” he said. “Both for the welfare of the child, and because it is a huge proof of concept that you can cure someone if you can treat them early enough.”

Of course, with adults it is very hard to pinpoint the exact moment of infection and know what really is early enough.