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									            Hope springs from the sharing of knowledge
                  French AIDS research with the developing countries

Panneau 1

Titre : The reasons for a commitment

Texte: In the face of certain realities, it is impossible to sit idly by. The AIDS crisis in the developing
countries demands action. The impact of the epidemic on the men and women of these regions, on
their societies, is so huge that France, with its close ties of solidarity, friendship and cooperation with
many of these countries, notably in Africa and South-East Asia, is duty bound to join with them
wholeheartedly in the fight against the HIV/AIDS epidemic. This fight is marked by glaring and
unacceptable inequality in access to prevention and to treatments in the developing world. Something
had to be done to show that broad access to drugs, to healthcare and to prevention is perfectly feasible
in the developing world.

France, at the behest of the Ministry of Foreign Affairs, therefore undertook a vast research program
in, for and with the developing countries, notably through its National Agency for Research on AIDS
and Viral Hepatitis (ANRS). The primary goal of this research has always been to furnish irrefutable
scientific evidence on which to base the public health policies that need to be implemented. It has also
shown that in the developing countries treatments are just as effective as in the developed world, that
patient compliance is just as good, if not better, and that access to treatment encourages prevention and
screening. This research has also helped to shed light on the mechanisms of price reduction for AIDS
drugs and has demonstrated that progress in developing countries can be enhanced by investing in
treatment access.

France’s involvement in AIDS research in the developing countries has helped the international
community to see that health is an absolute priority for these regions of the world. This is no more than
it should be, health being by definition the right of each and every human being.

Prof Michel Kazatchkine,
Ambassador in the fight against HIV/AIDS and communicable diseases

Health, the right of every human being

Panneau 2

Titre : AIDS, an infection, a disease
Chapo : Keys to understanding AIDS.

texte: AIDS is a disease caused by a virus, HIV (human immunodeficiency virus). HIV is transmitted
during sexual relations, through exposure to blood, and through mother-to-child transmission during
pregnancy, childbirth and breastfeeding. There are no other modes of transmission and there is no
risk of infection through everyday contact with infected people.
To avoid HIV infection or transmission:
    -      use a condom each time you have sex;
    -      avoid sharing objects that may be soiled by infected blood and could come into contact with
           your own blood;
    -      give your infants formula feed rather than breastfeed them where possible if you are a mother
           infected by HIV.
HIV principally infects cells essential to the immune system—CD4 lymphocytes—and uses them to
multiply. This process leads to the progressive destruction of the CD4 lymphocytes. After several
years, the immune system can no longer adequately protect the body and various diseases take hold.
This is the stage at which we speak of AIDS (acquired immune deficiency syndrome).

Titre : Effective treatments
Texte: We have drugs called antiretrovirals that are active against HIV. By combining several
antiretrovirals (triple-drug therapy), we can block the multiplication of the virus and so halt the
progression of the disease. Antiretrovirals considerably reduce mother-to-child transmission of HIV.
But the treatments do not eliminate the virus and long-term triple-drug therapy can have adverse

    -      Killer cell: cell able to destroy cells infected by a virus.
    -      Viral load: quantity of virus present in the blood.
    -      CD4 lymphocyte: one of the white blood cells of the immune system and the main target of
    -      CD8 lymphocyte: immune system cell. Some CD8 lymphocytes are killer cells able to attack
           the virus.

   -   Resistance: capacity of a virus to resist the action of a drug targeted against it. The drug then
       becomes less effective or ineffective.
   -   Seropositivity: this means that the person’s blood contains antibodies against HIV, indicating
       that s/he has been infected by the virus.
   -   Immune system: body’s system of defense, in particular against infectious agents (viruses,
       bacteria, parasites).

Acquired Immune Deficiency Syndrome

Panneau 3 – carte

Title : Number of people around the world who are living with HIV/AIDS
39.5 million (37.2 million adults, 17.7 million of whom are women, and 2.3 million children
under 15)
(Alléger la carte : laisser les chiffres et enlever le nom des continents)

24.7 million in Sub-saharan Africa
7.8 million in South and South-East Asia
1.7 million in Latin America
1.7 million in Western Europe and Central Asia
1.4 million in North-America
750.000 in East Asia
740.000 in Western and Central Europe
460.000 in North Africa and the Middle East
250.000 in the Caribbean
81.000 in Oceania

Source : UNAIDS/Who, 2006

Texte principal : French research in the developing world

Public bodies contribute to research in the developing world, notably :

- French National Agency for Research on AIDS and Viral Hepatitis (ANRS). Created in 1989, the
ANRS runs, coordinates and funds research in France on AIDS and viral hepatitis. With backing from
the Ministry of Foreign Affairs, the ANRS conducts research programs in the developing world in

partnership with local research scientists and physicians. It receives support from teams in research
bodies, universities, and hospitals, both in France and abroad.

- Development Research Institute (IRD). The IRD conducts research programs focused on the
relations between people and their environment in the developing world, with a view to enhancing
them through, for instance, improvements in health.
- Institut Pasteur and its international network. The Institut Pasteur is a private foundation whose
mission is to contribute to the prevention and treatment of diseases, first and foremost infectious,
through research, teaching, and public health initiatives.
- French National Institute of Health and Medical Research (Inserm). Inserm is the only French
public organization entirely dedicated to biological, medical and public health research. Its
researchers are committed to studying all human illnesses, whether common or rare.
- French National Center for Scientific Research (CNRS) The CNRS in active in all fields of
scientific endeavor.
- Hospitals and medical schools are important partners in the clinical research carried out in the
developing world.

[Encadré 1]

Titre : A North/South partnership
Research cannot thrive without partnership. Researchers of developing countries are involved in both
designing and conducting studies. Projects are carried out in coordination with the health authorities
of the countries.

[Encadré 2]

Respect of ethics
Research respects ethical rules and good practice, in particular in terms of the protection of people
who participate in studies.

Panneau 4

Titre : One virus, several viruses

Chapo: There is not one AIDS virus but several.

Texte : In 1983, research scientists at the Institut Pasteur in Paris and physicians identified a first
virus, HIV-1, or human immune deficiency virus. Soon after, other French teams studying diseases of
African origin discovered that there were several subtypes of HIV-1.

In 1986, French researchers and physicians identified a second virus, HIV-2, which is particularly
present in West Africa.

All of this research work mapped out the geographical distribution of the AIDS viruses.

HIV is a lentivirus, which causes a disease that progresses slowly. Viruses comparable to HIV are
found in many species of monkeys. Most HIV-1 subtypes emerged from a virus found in
chimpanzees, while HIV-2 derives from a virus of the sooty mangabey. The HIV strains responsible
for the AIDS epidemic have arisen through monkey-to-human transmission through blood exchange,
via hunters, butchers, bushmeat traders, and so on.

Encadré 1:

Titre : The HIV family
Texte: HIV-1.

There are three groups of HIV-1: M, O, and N. Group M is implicated in most infections around the
globe. It comprises 9 viral subtypes, classified from A to K, and numerous recombinant forms.

Two main HIV-2 subtypes have been identified: A and B.

Panneau 5

Titre : Unraveling HIV infection

Chapo : We are not equals before the risk of HIV infection and disease.

Texte : The risk of HIV infection is high during unprotected sex and when a needle is shared with
someone who is seropositive. Yet a very small number of people do not become infected by HIV,
despite repeated exposure to the risk of infection. Research teams from France and developing
countries have tried to uncover the reasons for this apparent “natural protection” against HIV.

Certain cells of the immune system, notably natural killer cells and CD8+ lymphocytes, may secrete
molecules that prevent infection. In some cases, the cells targeted by HIV, CD4 lymphocytes, also
seem able to resist the virus.

However, the “natural protection” against HIV infection probably involves a number of factors, both
immune and genetic, which vary from one person to another.

These factors could explain why certain seropositive subjects show no signs of the disease, even 20
years after having been infected.

Encadré 1

Titre : Major implications
Text : This research will perhaps lead to new treatments, and particularly to an HIV vaccine.

Panneau 6

Titre : Proposing medical management suitable for the developing countries

Chapo : HIV/AIDS treatments are just as effective in the developing as in the developed
countries. It was another matter demonstrating it !

Texte: Researchers offer treatments and patient management appropriate to the available resources
and living conditions of local populations.

Titre : Efficacy of HIV treatments.
Antiretrovirals block the multiplication of HIV and arrest progression of the disease. Several studies
have shown that triple antiretroviral therapy is as effective and well tolerated in the developing as in
the developed countries, notably simplified drug treatments involving a single daily dose.

Simplified treatments

Panneau 7

Titre : Compliance with treatments.
Research has shown, notably in Senegal, that compliance, i.e., the ability of a person to take his or
her treatment correctly, is just as good in the developing as in the developed countries.

Titre : Prevention and treatment of opportunistic infections.
When a seropositive person’s immune defenses are weakened, s/he risks developing opportunistic
infections, which are caused by microorganisms or parasites that are usually kept in check by the
immune system. A trial performed by Ivorian and French teams has shown in Africa that opportunistic
infections can be greatly curtailed by taking one daily tablet of an inexpensive drug (cotrimoxazole).
Another study has improved management of lung infections in Africa and in South-East Asia. Trials of
other opportunistic infections, as tuberculosis, are currently under way

Titre : Suitable follow-up tools.
Blood tests are used to monitor treatment efficacy. They measure the number of CD4 lymphocytes,
which decreases at the time of HIV infection, and the viral load, i.e., the quantity of virus. Tests
suitable for use in developing countries have been developed: they are inexpensive and can be
performed perfectly reliably in laboratories with limited resources.

All this research work clearly showed that there were no medical obstacles to the use of
antiretroviral treatments for seropositive individuals in the developing countries.

Measures applicable to everyone

Panneau 8

Encadré 1

Titre : Validating the efficacy of generic drugs
Texte: Generic drugs are copies of brand name drugs that are just as effective but less expensive.
French and Cameroonian physicians were the first to demonstrate scientifically the efficacy and safety
of triple-drug therapy in a single-dose generic formulation.

Encadré 2

Titre : An early warning system for viral resistance
Texte: HIV tends to undergo changes and so can become resistant to treatment. Thanks to an early
warning system, it has been observed that some people, both in the developing and developed
countries, are infected by resistant viruses.

Encadré 3:

Titre : Suitable diagnostic tests

Texte : A simple blood test detects either the antibodies produced by the immune system in the event
of infection, or the virus itself. If the test is positive, the person is seropositive, that is infected by HIV.
Researchers have developed HIV-detection tests usable in all the developing countries.

A simple blood test

Panneau 9

Titre : Children too...

Chapo : Despite progress in research, children rarely benefit from suitable treatment.

Texte: A trial in Cote d’Ivoire has shown that there are no medical hindrances to the therapeutic
management of seropositive children. The efficacy and safety of triple-drug therapy are equivalent to
those observed in children of the developed countries. A study is under way to simplify treatments, as
with adults, and to assess the efficacy of a single daily dose of three drugs.

French and Ivorian researchers have studied the difficulties encountered by seropositive children and
adolescents, many of whom feel unable to speak about their disease. It is important to provide them
with places where they can talk freely and exchange feelings.

Living as normally as possible

Panneau 10

Titre : Improving prevention of sexual transmission of HIV

Chapo : There are numerous cultural, religious, social, and economic obstacles to condom
use. Large studies have been set up to determine whether there are ways to complement
condom use.

Should herpes be treated to reduce the risk of HIV transmission ?
A trial in Burkina Faso in women infected by both HIV and a herpes virus, HSV-2, has shown that
treatment of herpes reduces the amount of the AIDS virus in genital secretions. Herpes treatment
could therefore lower the risk of sexual transmission of HIV.

Does male circumcision have a preventive role ?
A French-South African trial in South Africa was the first to suggest that the circumcision of adult
males not infected by HIV could reduce the risk of heterosexual transmission.

These two studies should not make us forget that the use of condoms is, at present, the most reliable
way of avoiding infection.

Panneau 11

Titre : Preventing mother-to-child HIV transmission
Chapo : This is one of the major advances achieved in the developed and developing countries
alike : the risk of HIV transmission from pregnant women to their child can be reduced.

Panneau n 12

Texte principal :Without treatment, 30% of pregnant women transmit HIV to their child.

Titre : Pregnancy and childbirth
The risk of mother-to-child HIV transmission can be reduced considerably by giving antiretroviral
drugs to seropositive women at the end of their pregnancy or at the start of delivery or both, as
demonstrated notably in three studies in Côte d’Ivoire , Burkina Faso and Thailand. With a single
drug, fewer than 20% of women transmit HIV to their child. With two or three drugs, the risk of
transmission is between 4.5% and 6.5%.

These findings are of considerable significance for seropositive women who wish to have
children. This type of treatment is now recommended in all developing countries.

Encadré 1

Titre : The value of screening
Text: In view of the efficacy of treatments to prevent mother-to-child transmission of HIV, it is obvious
that women should undergo a screening test before any pregnancy. This test also offers an
opportunity to provide information on sexuality, contraception and sexually transmitted infections.

Encadré 2

Titre : Seropositivity and the desire to have children
Text: Even though preventive treatments are effective, any pregnancy carries the risk of transmission
of HIV to the child. Some physicians therefore advise seropositive women to avoid pregnancy. Yet
researchers do not consider this view appropriate. In Africa, notably, having children is a central
feature of a woman’s identity. The role of medical teams is to support this desire to have children,
while minimizing the risk of transmission of HIV.

Protecting children
Safeguard mothers

Panneau 13

Titre 2 : Breast milk and the risk of transmission

Chapo : Breastfeeding is a frequent mode of transmission of HIV to children, particularly if
prolonged. However, it is not always possible to choose the alternatives that may be available.

Texte principal: 30 to 45% of children in the developing world are infected by HIV during
breastfeeding. Limiting this transmission is therefore a major research priority.

Seropositive women are now advised to avoid breastfeeding. The choice of how to feed their infant is
a real dilemma : most women resort to breastfeeding because of the fear of being stigmatized. Also,
there is a risk of infectious diseases or malnutrition if the child is not properly bottle-fed. A study in
Abidjan, where prolonged breastfeeding is the rule, among HIV-infected women receiving
antiretrovirals at the time of delivery, and who had access to drinking water, showed that it is possible
to consider bottle-feeding or early weaning.

Encadré 1

Titre : Treatment during breastfeeding ?
Several French and African studies are currently evaluating the value of giving antiretroviral therapy
either to the mother or to the child throughout breastfeeding.

Early weaning

Panneau 14

Titre : Inequalities and vulnerability: better understanding makes for better solutions

Panneau 15

Chapo: Social and political inequalities are factors in vulnerability to AIDS, notably for women.

Texte principal : Not everyone has the same risk of catching AIDS in the developed world, or in the
developing countries. Sociologists, demographers, anthropologists, and others have undertaken
studies in the developing countries with a view to understanding the social, economic and political
underpinnings of the epidemic.

Inequalities between men and women.
Women are more vulnerable to HIV than men. This vulnerability is first of all biological, but also social.
Women are rarely able to insist that their partner use a condom, notably when that partner is their
husband. When they discover they are seropositive, many women hesitate to speak of their plight
because they fear rejection.

The impact of poverty.
Lack of resources leads the poorest women, notably adolescents, to have sex in exchange for money.
Yet in sex-for-money relations it is hard to insist on condom use, which explains in part why the
frequency of infection is much higher in young women than in young men in the developing countries.

Influence of political context
In societies blighted by political instability and conflicts, displacement of populations, sexual violence
and economic dependence are rife, and this has been shown to contribute to the dissemination of
HIV. It has also been observed in countries like South Africa and the Democratic Republic of Congo,
that the most disadvantaged populations are harder hit by the epidemic in a climate of violence and
social inequality.

Encadré 1

Titre : Denial of homosexuality
Texte : A study in Senegal has shown that HIV infection is much more frequent among men who have
sex with other men than in the general population. Yet, this strongly stigmatized population is
generally not the subject of any prevention program.

Understanding the social underpinnings of the epidemic

Panneau 16

Titre : Increasing treatment access

Chapo : France has sought to increase access to treatments in the developing countries by
demonstrating that such access can be economically viable.

Texte principal : A large research program was initiated in the mid-1990s to seek evidence for the
feasibility of making HIV/AIDS drugs available in the developing countries and to determine the
conditions that would optimize access.

Access to drugs is possible
The researchers showed that medical management of HIV-infected people was just as effective in the
developing world as in the developed countries. Once financial barriers to access to drugs are
overcome, patients’ compliance with treatment is equivalent.

Value of generic drugs
Researchers have examined the possibilities for distribution of generic drugs in the developing
countries. They have analyzed the restrictions imposed by international trade agreements and how
they can be surmounted to some degree.

Financial hurdles to overcome.

Panneau 17

The question of drug pricing.
A research study in 13 countries has identified the mechanisms of price fixing by pharmaceutical
companies. The introduction of increased competition through the availability of generic drugs is the
best means of guaranteeing a steep drop in the prices of all drugs for the developing countries.

Macroeconomic impact of the epidemic
The AIDS epidemic lays waste to human resources through reduced production capacity of working
adults and their descendants. This impact may prove disastrous for the development of the most
affected countries of sub-Saharan Africa (20 to 40% drop in GNP by 2010 or 2015). Projections of the
effect of generalized access to treatments suggest that this impact can be thwarted, thereby
preventing countries from getting caught up in a vicious circle of poverty worsened by the AIDS

This vast research program has greatly helped to change attitudes, notably in large
international organizations, concerning access to drugs in the developing world.

Encadré 1

Titre : The example of Brazil
Texte: Brazil has set up an industry capable of manufacturing generic HIV/AIDS drugs. This has given
the Brazilian authorities a strong hand in negotiating price reductions with the license-holding
pharmaceutical firms. Brazil has decided to supply suitable treatments free of charge to all HIV-
infected Brazilians who need them. This policy has been shown to have major public health benefits.

Exhibition organized by the ANRS (Scientific Information and Communication service), financed by the
Ministry of Foreign Affairs

Scientific committee :
Françoise Barré-Sinoussi, Institut Pasteur
Brigitte Bazin, ANRS
François Dabis, Inserm
Annabel Desgrées du Loû, IRD
Conception :   ANRS/RCP Communication
Design : Gilles Regnery

Changing people’s attitudes


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