FRESH pro­gram com­bines ba­sic sci­ence with so­cial ben­e­fits for women at HIV risk

Iran Daily - - Health -

Apro­gram es­tab­lished by in­ves­ti­ga­tors from the Ragon In­sti­tute of Mas­sachusetts Gen­eral Hos­pi­tal (MGH), MIT and Har­vard is ad­dress­ing the per­sis­tently el­e­vated risk of HIV in­fec­tion among young women in South Africa from two an­gles — first, in­ves­ti­gat­ing bi­o­log­i­cal fac­tors that mod­u­late in­fec­tion risk along with the early im­muno­logic events fol­low­ing vi­ral ex­po­sure and sec­ond, al­le­vi­at­ing the so­cioe­co­nomic fac­tors that limit op­por­tu­ni­ties for young women, the group at great­est risk of in­fec­tion in the re­gion of the world hardest hit by the HIV epi­demic.

Mem­bers of the Ragon In­sti­tute team re­ported on the first five years of the FRESH pro­gram in a com­men­tary pub­lished in Sci­ence Im­munol­ogy, med­i­calx­ re­ported.

Krista Dong, MD, of the Ragon In­sti­tute and the Di­vi­sion of In­fec­tious Diseases at MGH, FRESH pro­gram leader and a coau­thor of the report, said, “The South African gov­ern­ment’s an­tiretro­vi­ral treat­ment pro­gram has en­abled a re­turn to near nor­mal life ex­pectancy for those who have be­come in­fected, but rates of new in­fec­tions among young women con­tinue al­most unchecked.

“Gen­der in­equal­ity re­sults in dis­em­pow­er­ment — in­clud­ing a lack of means for women to pro­tect them­selves from in­fec­tion — and eco­nomic de­pen­dence. It is es­ti­mated that 5,000 young women in South Africa be­come in­fected ev­ery week. Per­form­ing med­i­cal re­search in such vul­ner­a­ble pop­u­la­tions re­quires spe­cial con­sid­er­a­tions to en­sure par­tic­i­pants’ safety and well-be­ing, so we sought to ad­dress ma­jor non-hivre­lated chal­lenges fac­ing th­ese young women while con­duct­ing re­search aimed at de­vel­op­ing an ef­fec­tive HIV vac­cine.”

Launched in De­cem­ber 2012, the FRESH study was es­tab­lished in a shop­ping mall in the Um­lazi town­ship of Kwazulu-na­tal, a South African prov­ince that has one of the high­est rates of HIV in­fec­tion in the world. The lo­ca­tion was cho­sen be­cause of the re­luc­tance of many South Africans to visit clin­ics un­less they are se­ri­ously ill due to stigma associated with typ­i­cal HIV test­ing and treat­ment sites.

The pro­gram en­rolls young women ages 18 to 23 — not in school, un­em­ployed, Hiv-neg­a­tive — in groups of 30 per month to cre­ate peer sup­port groups.

Par­tic­i­pants visit the clinic twice a week to par­tic­i­pate in ses­sions rang­ing from self-es­teem, re­la­tion­ships and gen­der-based vi­o­lence, and HIV pre­ven­tion and treat­ment to ca­reer de­vel­op­ment, com­puter train­ing and start­ing a small busi­ness. Par­tic­i­pants un­dergo HIV test­ing at each visit, with more com­pre­hen­sive blood and cer­vi­cal-vagi­nal sam­pling ev­ery three months.

Ini­tially, an­tiretro­vi­ral treat­ment was not pro­vided at the time a new in­fec­tion was de­tected but was only started af­ter a par­tic­i­pants’ CD4 count dropped be­low 350, fol­low­ing the treat­ment guide­line for South Africa at the time.

Ap­proval was granted 18 months into the pro­gram to start treat­ment im­me­di­ately af­ter an in­fec­tion was de­tected. Most re­cently, FRESH has be­gun to of­fer pre-ex­po­sure pro­phy­laxis or ‘PREP’ — an­tiretro­vi­ral drug treat­ment given to pre­vent HIV in­fec­tion — which is not yet be­ing pro­vided by the South African gov­ern­ment.

Among the more than 1,000 women who have com­pleted the nine- to 12-month pro­gram, more than 85 per­cent have been placed in jobs or in­tern­ships, started their own small busi­nesses or re­turned to school. Some have be­come the pri­mary bread­win­ners for their house­holds.

Although the rate of new in­fec­tions among FRESH par­tic­i­pants has re­mained con­sis­tent since the pro­gram launched, the in­ves­ti­ga­tors rec­og­nize that the be­hav­ioral changes that can im­pact HIV risk will re­quire sus­tained im­prove­ment in ca­reer and ed­u­ca­tional op­por­tu­ni­ties for the women and a re­sul­tant shift in cul­tural norms.

Ba­sic re­search aris­ing from the FRESH study has iden­ti­fied bi­o­logic fac­tors that may con­trib­ute to a higher risk of HIV in­fec­tion among South African woman — in­clud­ing the com­po­si­tion of the bac­te­rial mi­cro­biome in the gen­i­tal tract among lo­cal women, a high in­ci­dence of other sex­u­ally trans­mit­ted in­fec­tions, and hor­monal lev­els re­lated to ei­ther a com­monly used con­tra­cep­tive or the nat­u­ral fluc­tu­a­tions of the men­strual cy­cle.

The abil­ity to study HIV in­fec­tion at its ear­li­est stages re­vealed that the rapid ac­ti­va­tion and pro­lif­er­a­tion of CD8 T cells, which usu­ally at­tack and de­stroy pathogens, quickly di­min­ishes as the im­mune cells be­gin to die off them­selves.

But par­tic­i­pants who can main­tain higher lev­els of CD8 cells have lower vi­ral lev­els, sug­gest­ing a pos­si­ble strat­egy for vac­cine de­vel­op­ment. Those who be­gin an­tiretro­vi­ral therapy as soon as in­fec­tion is de­tected have more ef­fec­tive CD8 func­tion with­out the typ­i­cal drop in CD4 lev­els, mak­ing them an ideal group for stud­ies aimed at po­ten­tially cu­ra­tive ther­a­pies.

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