A Fresh Front in the AIDS War 

From Ethiopian refugee camps to East Bay suburbs, a new class of compounds promises success where condom use has failed ­ to stem the spread of HIV.

In 1992, Bethany Young Holt was working in the refugee camps of southern Ethiopia, where thousands of people had fled to escape the civil war in Sudan. She was a master's student from UC Berkeley's School of Public Health, there for an internship with the Centers for Disease Control, which was rolling out an HIV prevention program. The camps seemed like an ideal place for it -- while very few of the Sudanese refugees were HIV-positive, commercial sex workers from Ethiopian cities were flooding into the camps in search of clients, and their HIV prevalence was 42 percent. It should have been a chance to avert a disaster.

Holt's job was to teach people to use condoms. "That was just a joke," she quickly realized. "The women all wanted them and the men wouldn't put them on for a hundred different reasons."

Many of these men were really just boys, Holt says. They were part of a culture in which a woman's social status is tightly linked to childbearing, and where husbands hold absolute authority over their wives. They were stuck in a strange place during hard times, and at least in the very small sphere of their marriages they were still the boss. If they didn't want to wear condoms, well, that was the way it was.

The Ethiopian sex workers couldn't convince the men to wear condoms either, and Holt shared their despair. The twin plagues of AIDS and extreme poverty had begotten a generation of young women compelled to do desperate things to survive. Some had become prostitutes to support sick parents or siblings. Others had been kicked out of their families after testing HIV positive. Some had hoped to achieve a better life by doing well in school, but then contracted HIV from their teachers, who demanded sex in return for good grades. One of them, an eighteen-year-old who was fluent in English and yearned to be a doctor, would simply follow Holt around and watch her work. It's hard to let go of that sort of thing.

And Holt doesn't let go. A tall woman with shoulder-length blonde hair, fine features, and a sort of gentle, tired smile, she majored in biology in the hope of becoming a vet. Instead, she says, "I fell in love with Africa." After college she went to Mauritania with the Peace Corps, and then on to a variety of relief agencies including the United Nations' High Commission for Refugees. By the time she was working in Ethiopia with the CDC, her life's work had crystallized to a focus on HIV prevention. "It really was sitting in Ethiopia with these girls, who were so well-educated, really sweet girls," she recalls. "They had babies and mothers and they just had no options, and I realized, gosh, they're probably going to die."

It was impossible to ignore the searing irony: The young prostitutes, who existed on the fringe of their society, and the Sudanese wives, who were playing by its strict rules, were equally powerless to protect themselves against disease. The refugee wives, Holt says, "had absolutely no power to negotiate anything in their lives. They couldn't even go to the clinic in the camp without their husbands' consent. They would tell us that they knew their husbands were infected with diseases that could hurt them and their babies, but they couldn't do anything about it. They had been sold by their fathers in Sudan for ten cows, but now those cows were in Sudan and they couldn't get the cows back. That was their plight."

It is our plight too. Of the five million people newly infected with HIV every year around the globe, 60 percent are women.

It is significant that a disease many people still think of as primarily afflicting communities such as gay men and intravenous drug users has migrated so easily into the mainstream, into women of childbearing age, particularly women of color, and therefore into every neighborhood and every type of family. On the whole, these women are not engaging in what most people consider risky behaviors. Very often they are married, they are monogamous, they are mothers, and the men they love are the source of their infection.

While it might be comforting to believe that these HIV-positive housewives all live in developing nations, they do not. In California, women have become the fastest-growing population of AIDS patients, and AIDS the leading cause of death for African-American women ages 25 to 34. Most of the women are picking up the virus through heterosexual contact. In fact, when Holt returned from Africa, her next project as a Cal graduate student was to study the health of women in Oakland. "It was amazing to me, the parallel between women in Africa and poor women in our own backyard," Holt says.

Here again were women in abusive or economically dependent partnerships with little power to negotiate sex or condom use. Here were HIV-positive women infected by long-term male partners. Here were men who refused to use condoms or to take HIV tests for fear of being suspected of being intravenous drug users or of having sex with other men on the down-low.

Holt, currently a lecturer at Cal's School of Public Health, believed there had to be a better way to protect women. So in the late '90s, she joined with other public-health experts and researchers who had long envisioned the next best thing to a cure or effective AIDS vaccine: something new to prevent its transmission during sex. Ideally, it would be discreet and female-controlled. It would be cheap enough that clinics in the developing world could give it away, and people in industrialized nations could buy it for about the price of condoms. Most of all, it would have to work.

After twenty uphill years, it is almost here. It's called a microbicide, a new class of experimental drugs that kill or block HIV on contact. Most are colorless, tasteless, odor-free, and could be applied as lubricating gels, foams, suppositories, or vaginal rings. They've been dubbed "invisible condoms" -- most likely, a sexual partner wouldn't even know they're there. Some can also act as contraceptives; others can kill not only HIV but a broad spectrum of sexually transmitted diseases and common vaginal infections. There are fourteen microbicides now in clinical trials and another fifteen in laboratory development, which employ a range of disease-thwarting strategies (see sidebar "Halting a Killer"). And there is yet another option undergoing preliminary safety tests. If ultimately shown to be effective, it could prove the cheapest, lowest-tech solution imaginable for impoverished women around the world. It literally grows on trees. You probably bit into it the last time you took a tequila shot.


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