[rael-science] Staying alive: the women who are immune to Aids‏

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The Raelian Movement
for those who are not afraid of the future : http://www.rael.org
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Staying alive: the women who are immune to Aids

http://www.guardian.co.uk/world/2007/may/27/aids.features

In the past 30 years Agnes has had unprotected sex with up to 2,000
infected men. Yet she and a small number of her fellow sex workers are
still free from Aids. Stephanie Nolen travels to Majengo, a slum in
Nairobi, to meet the extraordinary women and researchers who are
changing the history of HIV

The Observer, Sunday 27 May 2007

I lay down to test the mattress: it was lumpy and totally unyielding,
not the sort of place one would want to spend much time, which seemed
a little odd, given the purpose of this room. Agnes Munyiva saw my
wince, laughed and patted the bed. 'You need it to be hard, because
otherwise you could get hurt when the men are pushing on you,' she
explained.

The mattress, stuffed with lumpy cotton and resting on a plain metal
frame, fills most of her room, just one metre by two. The walls are
made of mud, the roof of scraps of tin. The air has a tang from the
raw sewage and rotting food scraps in the alley outside, and Agnes
tries to keep the clouds of flies at bay with a crisp white muslin
curtain in the doorway. Remnants of linoleum, pieced together like a
quilt, cover most of the dirt floor. She has a kerosene burner for
making tea and a gas lantern. Two mouldy calendars, giveaways from
insurance companies many years back, are tacked to the walls, the only
decoration. A collection of worn facecloths hangs drying on a small
clothesline. Beside the bed she keeps a large white box, containing
the best part of a gross of condoms.

Agnes rents this room for 900 Kenyan shillings (£6) a month, bed
included. She doesn't live here - she also rents another room, a bit
bigger than this one, on the other side of Majengo, a slum
neighbourhood on the edge of Nairobi. She shares that room with the
three youngest of her five children. They have never seen this one.
This room is just for work.

Agnes arrives here around six o'clock each morning, when the sun is
climbing in the sky, and she makes sure she is on the way home before
the sun sinks again 12 hours later - she is a lady of the evening who
works only in the daylight hours. There is plenty of rape and theft
and murder in Majengo in the daytime, but at night the streets are
completely lawless. When Agnes arrives in the morning, she sweeps the
patch of floor and the narrow alley outside. She makes a cup of tea,
sips it from a battered tin mug, stacks the cloths by the bed. Then
she takes a low three-legged wooden stool into the alley, sits down
and waits for business. 'Karibu,' she says as men pass - Kiswahili for
welcome. She gives them a wink and her slow smile that unfurls like
honey off a spoon. 'We all try our luck each time a person passes,'
she explained. 'If he stops to look at me maybe he is interested, but
if not, maybe he is used to someone else.' In front of every third or
fourth shack in the streets a woman sits on a stool, modestly dressed
like Agnes, who wore a bright wrap printed with blue and yellow
chickens on the day she introduced me to a working woman's life in
Majengo.

Most days a man stops before she has been in the alley for half an
hour. 'They are people on their way to work. Or men on the road who
spent the night away from their wives - they pass here for breakfast.'
When a man stops at Agnes's soft 'Karibu', she invites him to step
into her room. 'Most men are discreet - the ones with wives want to
get in the door very quickly.' Inside, they negotiate. The price is
set at between 50 and 100 shillings - 37p to 75p. She slides the door
closed, but the scratchy sounds of a neighbour's transistor radio
drift through the screened window; her customer knows he must be
silent. 'We even tell them not to make a lot of noise,' Agnes said,
sounding very prim, 'because there could be a family in the next
house.' She removes her wrap, lies back on the bed, her arms above her
head. She does not embrace the client, whispers no encouragement. This
is a brisk transaction. 'If your five minutes are over and you are
still there,' she pointed at her chest, 'you have to pay another 50
shillings,' she said firmly. Business concluded, her client steps over
the curious chickens in the doorway and back out into the alley, and
Agnes cleans up with the cloths and a pitcher of water from the
standpipe at the end of the alley. Then she returns to the stool.

This interaction is repeated a dozen times each day. A fair portion of
the men who stop have spent time with Agnes before. 'The service must
have been good, so they come back,' she told me with a giggle. At the
end of the day, she padlocks the door and takes home perhaps 500
shillings, enough for some food bought at the market stalls on the
way, and a bit put aside for the next instalment of the children's
school fees, or some kerosene or soap.

Agnes came to Nairobi from Machakos, two hours to the east by bus, in
1971. She was 20 years old. There was only the exhausting work of
farming at home, and she hoped to find a job in the city. Before long
she was hired as a maid in a middle-class house. That lasted a year,
and then she found more work mending clothes, and then casual labour
in the industrial area on the edge of the booming city. That led to a
job making paper bags in a factory - but she injured a finger in the
machinery after a couple of years and was fired. By then she had had
three small children, fathered by a couple of boyfriends who hadn't
stuck around. Her mother had died back home, her father was unwell,
and she felt there was no one in Machakos to whom she could turn.

Agnes had only one room, then, in Majengo, the sort of chaotic
community at the edge of the city where so many of Africa's rural poor
end up. Majengo is built around a vast market for mitumba -
second-hand clothes given by North Americans and Europeans to charity
shops that end up shipped to Africa in giant bales. Traders from all
over east Africa come to hunt for bargains in First World cast-offs.
The market also sells everything from plastic washbasins to
jerry-rigged, scrap-metal satellite dishes. There are food stalls and
tearooms and hostels for the travellers.

Thousands of people move through here every day, many with a little
disposable income suddenly in their pocket: like similar communities
the world over, it is a natural centre for sex work. In addition to
the travellers from out of town, men from all over Nairobi - police
officers, civil servants, welders, street sweepers, teachers and taxi
drivers - seek out the anonymity of the vast market for their
occasional sexual encounters.

When Agnes was despairing about how to make money, how she would
survive in the city, her neighbours suggested she try umalaya, sex for
money. 'In the neighbourhood there were other women who were doing it,
and they encouraged me to try it. I had children who needed food.' And
so, with great reluctance, she began to sit on a wooden stool outside
her home and try to catch the eye of men who passed by. She never
imagined, in those first few weeks, that she would be earning a living
this way 30 years later.

Today, thousands of women work in the alleys of Majengo and the other
sprawling slums of Nairobi, but only one or two of Agnes's friends
from her first days in the business are still around. 'The ones I
started with are no longer here - they have died,' she said simply.
'Most of the people I have worked with have died.' Beginning in the
early Eighties, women started to get thin, with sharp coughs and white
fur that coated their mouths and throats; back then they called the
illness Plastic, Agnes said, because city workers hastily wrapped up
the bodies of people who died that way in plastic sheeting. Some of
the women died there in Majengo, and others went back to the village
when they grew too sick to work. But Agnes remained healthy, year
after year.

What happened to her - or, more accurately, what didn't happen to her
- would prove to be one of the greatest discoveries in the 25-year
battle with Aids. She would acquire, over the next two decades, a
certain fame, in the world of virology and infectious disease, as one
of those Nairobi prostitutes. But Agnes's body would be slower to give
up its secrets than anyone imagined.

This story starts with chancroid, a venereal disease that causes
suppurating ulcers on the genitals. On the other side of the world
from Nairobi, in the Canadian prairie city of Winnipeg, there was an
outbreak of chancroid in the late Seventies, and infectious-disease
experts at the University of Manitoba began to investigate. Before
long they had figured out how to grow the bacteria in the lab, but the
outbreak had quickly been brought under control by public health
officials, and the researchers were left without patients. That might
have been the end of it, had a Winnipeg microbiologist not got talking
to a colleague from the University of Nairobi at a conference a few
months later. 'You want chancroid?' the Kenyan asked. 'We've got
chancroid.'

And so Allan Ronald flew to Nairobi in 1980. He soon noticed that
sexually transmitted infections, or STIs, such as chlamydia and
gonorrhoea were rampant. He also noticed that most of the people
seeking help at government clinics for these infections had in common
the fact that they frequented prostitutes in an industrial slum. He
and a couple of colleagues set up a shop-front clinic in Nairobi,
offering free treatment to anyone in return for participation in
medical research. Before long the operation expanded into slums around
the city. They were candy-store settings for young western
researchers, with more weird microbes coming through the door in a
single morning than they might see in a year back home. And their
patients were more than happy to participate, in exchange for the
top-notch health care they could never have afforded to purchase in
Nairobi. 'Here we got treatment if we were diagnosed - the city clinic
never had any drugs,' said Agnes, who first attended a clinic in 1983
and soon became a regular. And, she said, she and the other women felt
less judged in the research clinic; no one gossiped about the way they
earned their living.

In those first few years, the Manitobans and colleagues from other
universities in the west who joined them did some important research
on sexually transmitted diseases, and the impact on children whose
mothers were infected with gonorrhoea or chlamydia. But the discovery
that would rock the scientific world came from the whim of a graduate
student. In 1985, Joan Kreiss, a student researcher from the
University of Washington, decided to test the sex workers, including
Agnes, for HIV. The virus had been identified in New York four years
earlier, and Kreiss wanted to use the new test for antibodies to HIV.
Her older colleagues were dubious. They suspected, from post-mortems
on patients who had symptoms similar to those being reported in New
York, that HIV was present in Nairobi - and years later, tests of
stored blood from east Africa would show that, in fact, some
communities in the region at that point had infection rates as high as
20 per cent. But there was not a single documented case of Aids in
Kenya at the time, and many scientists were doubtful that women could
even catch the disease through sex. So no one was prepared for what
Kreiss found. Two-thirds of the women she tested were HIV-positive.

Her findings - one of the earliest recorded signs of the African
epidemic - did not go down well. The government of Kenya threatened to
deport the foreign researchers and shut the whole project down. 'The
government said, "It's not true what you are saying! You're going to
drive the tourists out of Kenya!"' recalled a rueful Elizabeth Ngugi,
a community health professor at the University of Nairobi. She was
working ('in the mud and in the sun and in the rain and in the dust')
to get to know Agnes and the Majengo women, building relationships
that would be the core of research through the decades. She soon
organised 600 women into support groups, brought them into the clinic
for classes on sexually transmitted diseases, gave them condoms and
encouraged them to present a united front to clients, insisting on
protected sex.

Over the next few years, research involving the women yielded two big
discoveries. The first was that mothers passed HIV to their babies in
breast milk. Researchers already knew there was some transmission of
the virus this way, but a study in the slum showed that the longer a
mother breastfed, the higher was the risk of transmission - and that
far from being negligible, this was in fact a major source of
infection. The second major finding was that a person with a
conventional STI, such as gonorrhoea, has a much higher chance of
contracting HIV - as much as 70 per cent higher - than a person not
infected. All of this, however, paled beside a discovery that emerged
in the late Eighties. Frank Plummer, now the director of Canada's
Centre for Infectious Disease Prevention and Control, in Ottawa,
worked in the Nairobi project from its early days. He was intrigued by
these HIV-positive women, who gave the lie to so much of the
predominant thinking about Aids at the time - that it didn't exist in
Africa, that women couldn't get it, that heterosexual sex was no real
risk. By 1988, he had noticed something bizarre: over time, more and
more of the women were testing positive for HIV - but not all of them.
Some, including Agnes, were still around, three and four and five
years later, and in their biannual HIV tests they were still negative.
Plummer began to track them closely, and concluded that a small number
of the women - perhaps five per cent - were simply not getting
infected. 'They're basically immune to HIV,' he told me. 'Their immune
systems for whatever reason are able to recognise and kill HIV.' In
the study of a particularly impenetrable virus, this was a massive
discovery.

Keith Fowke, a professor of medical microbiology at the University of
Manitoba, who was then a student working under Frank Plummer in
Nairobi, explained it like this. 'We did the models and found that
these women were not just really, really, really lucky - it was beyond
the statistical chance of luck playing a role. We estimated that many
of these women have had 500 to 2,000 sexual exposures to infected men
when they weren't using a condom.' Surveys found that a quarter of the
men who frequented sex workers in the area were HIV-positive. And
while Ngugi's shack-to-shack education efforts had early success
getting Agnes and the other women to use condoms with some of their
one-off clients, there were still many exceptions: men would pay extra
not to use condoms - money that women hard-up for cash were reluctant
to forgo - and sex workers didn't use them with their 'regulars', men
they saw every week or two. Ngugi's surveys found that the women used
condoms, at best, only 75 per cent of the time, so there could be no
question that Agnes and a handful of others had been routinely exposed
to HIV over a decade or more.

Yet they weren't infected. It wasn't good nutrition - the women did
not earn enough to eat well - and it wasn't that they somehow took
better care of themselves, because they had had other STIs and
ailments. Something else was happening to make these women immune.

Then Plummer and his team noticed something even more peculiar. The
women's likelihood of being infected with HIV/Aids was related to the
length of time they had been doing sex work: the longer a woman had
been selling sex in Majengo, the less likely she was to be infected.
If she'd been doing it for five years and was still HIV-negative, the
data suggested, then the odds were she was going to stay that way.
These findings were so counterintuitive that Plummer and his team
struggled to find anyone who would publish them. The phenomenon didn't
get major attention until two years later, when he described the
resistant women at the International Aids Conference in Amsterdam in
1992.

Once the public really began to understand that there were people who
were immune to Aids - and the dark irony that it was the sex workers
vilified for spreading the disease - Majengo became a focus of
attention. Television news teams poured into the slum, clamouring to
meet the women. The attention left Agnes baffled. 'I just thank God,'
she said then, as she does now. She couldn't explain why she wasn't
sick. She could just give thanks for it at Mass every Sunday morning.

The researchers, however, were frantically trying to decode what was
going on in the bodies of Agnes and the other women. 'Either the virus
couldn't infect their cells at all or the virus could but their bodies
were clearing the infection in some way,' explained Fowke. 'But when
we isolated the blood cells of some women in the lab and exposed their
cells to HIV, it could get inside their cells and was able to
replicate and able to grow just fine. So we started looking at their
immune system - HIV was able to establish initial infection and the
immune system was able to clear it,' Fowke said. 'We've really found
cells that can kill HIV in these women.'

Agnes has, in effect, a callus: the first time she was exposed to the
virus, her body produced enough killer T cells to fight it off. This
part isn't unique - the body of every person who is exposed to HIV
mounts some level of response, and sometimes manages to fight it off;
a single exposure does not guarantee infection. But Agnes's body, it
seems, not only produced sufficient and strong enough cells to fight
the virus off the first time, it then produced a whole raft of those
killer Ts, flooding her system with guardians whose sole brief was to
keep an eye out for cells infected with HIV. The infected cells have a
distinct pattern of little bumps on them, called epitopes, which act
like a red rose in the lapel as far as the killer Ts are concerned,
letting them know just which cells they want to hunt down. Then every
subsequent time - probably thousands of times - that HIV got into
Agnes's body, her killer T cells drove it back. A person does not
normally maintain a large number of killer T cells for a long period -
just long enough to kill something off, then production drops. But in
Agnes, fairly constant exposure to HIV kept her killer T cell count
high.

This conclusion was reinforced when Plummer and his team noticed that
women who take a 'sex break' - who make a trip home to the village for
a few weeks, or save up a little money and leave sex work for a while
to try selling shoes instead, or hook up with a regular who keeps them
in cash for a year or two - were far more likely to get infected,
almost immediately, if they returned to sex work, even though
previously they had had years of apparent immunity. On the break,
their bodies stopped making the killer T cells, leaving them
vulnerable again.

The Nairobi women aren't the only people in the world immune to HIV.
Some Caucasian men have been found to have a genetic mutation that
means their cells lack one of the molecular 'hooks' that HIV latches
on to, and so they cannot be infected. And no doubt there are other
groups of people who, like these women, are able to kill off the virus
- but it is much easier to see, and monitor, in this community of
women who are repeatedly exposed to the virus than it would be in,
say, a group of nuns in a convent in Europe. They might be immune to
HIV, too, but how would anyone ever tell?

From the moment it became clear that Agnes and a handful of other
women in Majengo - about 100 to date - really could fight off the
virus, the researchers in Nairobi hoped that their biology would hold
the secret of an HIV vaccine. Soon a team from Oxford University was
at work on a vaccine that used the epitopes (the tell-tale bumps on
infected cells) that triggered Agnes's killer Ts. They hoped it would
provoke other people's bodies to produce killer T cells in the same
way that the real virus appeared to trigger production in the sex
workers. Trials began in Nairobi in 2001, and a second trial was
mounted by Pontiano Kaleebu and his colleagues in Entebbe a couple of
years later. But despite high hopes, the Oxford vaccine didn't cause
that explosion of killer T cells. And so it was back to the
painstaking work of trying to figure out the secret of Agnes's
immunity. 'Sometimes a vaccine feels impossibly far away,' sighed
Keith Fowke. 'All our knowledge about these HIV-resistant people is
interesting and I feel it's important... but it is frustrating.'

For Ngugi, watching as Aids decimates ever more of this community
where she has built such strong ties, the gains are hollow. 'Yes, it's
fascinating,' she told me. 'But sometimes I feel very sad. Sometimes
you are not a scientist but a friend, and you feel the emptiness
inside.'

There was a certain sense of breath-holding among the Nairobi
researchers when Plummer and his team first proved the women's bodies
were able to kill off HIV, but that breath has long since been let
out. Today, the research strategy in Majengo revolves around intense
study of Agnes and the other resistant women (who make up about five
per cent of the cohort at any one time), from analysing their genome
to breaking down the chemical components of the mucosal membranes in
their vaginas, in an effort to figure out what may be protecting them.
So far researchers have not found anything present in 100 per cent of
the women, so it may be that the protection comes from multiple
overlapping factors, including some that are genetic. There is a
strong family correlation - people related to an HIV-resistant woman
seem to be half as likely to get infected as people who are not
related.

Agnes is aware that she is a fascinating specimen. 'Most of the people
have been very interested in me,' she said matter-of-factly. But she
has no understanding of the biological basis for her HIV resistance.
'No one has told me,' she said with a shrug. She gets good, free
health care at the clinic for the occasional sexually transmitted
infection and also for respiratory infections which plague residents
of the polluted slum. So she is happy to give them her blood a couple
of times a year, and to enjoy a sense of contributing something to her
community.

But Agnes's survival has served to highlight a disquieting aspect of
this research. She has come to the clinic for more than 20 years. In
that time, more than $22m in scientific grant money has flowed through
the project, and many of the researchers have earned reputations as
the top experts in their fields. Yet Agnes and a handful of other
women are still selling sex, to an average of eight clients a day,
still for a dollar or two each time - although they say they would
like nothing more than to get out of sex work. When I asked her what
she would like to do instead, Agnes's broad face lit up. 'Any kind of
job I could do. I could be a cleaner or anything. But it's very
difficult to get a job - you have to know somebody to get a job.' And
Agnes said she doesn't know anybody who could help. With only limited
literacy after three years of primary school, and no other skills,
Agnes said she sees no other options. 'It's embarrassing, this
profession,' she said. She refuses to discuss what she does for a
living with her children, although she is sure they know. 'I've never
told them what I do, but I think they can see it. I think they know
what I'm doing is not good but they know I do it to provide for them.'

Agnes's frustration with her life in sex work raises troubling ethical
questions about research, the kind that bedevil investigations into
Aids vaccines, prevention technologies and treatment, all of which, by
definition, involve large groups of poor Africans, the people most at
risk. What obligation does a researcher such as Plummer have to the
women who have given him their blood for 20 years? What does this
project owe Agnes?

'Those are difficult questions,' Plummer told me. 'My philosophy has
been: try to help as many people as we can with what resources we have
so we can ultimately solve it. We provide treatment for a lot of
medical conditions and counselling for safer sexual behaviour and free
condoms and referral to other medical services - which prevents about
10,000 infections each year. We do have an obligation to provide some
basic level of care, and since 2004 we have provided anti-retroviral
treatment [ARV], which is an important step. But ARV drugs are not
going to solve this problem.' Plummer doesn't disagree that women like
Agnes need a route out of prostitution. 'I don't know what those ways
out are, though, and anything we could do is just working on the
margins - it's unlikely we'll be able to do anything to get them to
the point that they're not partially dependent on sex work: you can
only make so much money selling tomatoes or weaving baskets.'

His Kenyan colleague Elizabeth Ngugi is unconvinced by this line of
argument. 'These women have given the world such a huge body of
knowledge, but what has the world done to help them change? The
research findings have given us so much, but what have we given back?
There is more research money coming all the time - quite clearly there
is an imbalance.' In 2002, she received funds from a donor agency to
train 120 of the women in new skills such as dressmaking and
hairdressing, and she said 80 of them successfully made the transition
out of sex work. She has helped a few others make their way to local
benevolent agencies and out of the business, but most are stuck, and
the research budget includes no funds to give them other options - a
grim irony when, as she pointed out, they've educated all the women
about what a huge risk sex work is to their lives.

Plummer agreed that the women need basic education in numeracy and
savings and small-business skills. 'But you can't get a research grant
for that,' he said. The ethics of science today require that the women
get counselling and condoms, but ethics approval boards make no
demands about maths classes or instruction in how to set up an
alleyway beauty salon.

There is a small patch of grey at Agnes's hairline these days, and her
body has thickened to that of a woman of a certain age. 'I'm getting
old,' she said. 'There will be a time that I'm too old - at around 60.
Maybe 10 years from now clients will not even look for me. It will be
difficult.' Now she feels lucky to get 100 shillings from a client,
when a young woman newly arrived in Majengo might get as much as 300 -
although in any case, trade is not what it once was. 'Ever since we
got this disease, business has dropped. Most men go home to their
wives on the weekend.'

Of the men who still buy sex (and she manages to find nine or 10 each
day), most now agree to use condoms - but not all, and Agnes worries.
She would like to start a small business that would keep her family
when men no longer stop outside her room, but she used all the few
thousand shillings she had saved to put up a single-room house on the
land her father left her back in the village: insurance in case her
luck runs out and she needs to go home.

Agnes's mysterious immune system has garnered her considerable fame in
the world of Aids, but little else. She lives a life almost totally
unchanged from her first days in umalaya 30 years ago. 'I can buy our
daily food out of what I earn, and that's all,' she told me as we sat
in the shade of her bustling alley. 'I don't feel famous. It's only
that my problems push me to do sex work. If I could find something
else, I would.'

· This is an extract from Twenty-Eight: Stories of Aids in Africa by
Stephanie Nolen, published by Portobello Books on 28 May. To order a
copy at £11.99 with free UK p&p, call 0870 836 0885, or
visitobserver.co.uk/bookshop


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
WARNING FROM RAEL: For those who don't use their intelligence at its
full capacity, the label "selected by RAEL" on some articles does not
mean that I agree with their content or support it. "Selected by RAEL"
means that I believe it is important for the people of this planet to
know about what people think or do, even when what they think or do is
completely stupid and against our philosophy. When I selected articles
in the past about stupid Christian fundamentalists in America praying
for rain, I am sure no Rael-Science reader was stupid enough to believe
that I was supporting praying to change the weather. So, when I select
articles which are in favor of drugs, anti-Semitic, anti-Jewish, racist,
revisionist, or inciting hatred against any group or religion, or any
other stupid article, it does not mean that I support them. It just
means that it is important for all human beings to know about them.
Common sense, which is usually very good among our readers, is good
enough to understand that. When, like in the recent articles on drug
decriminalization, it is necessary to make it clearer, I add a comment,
which in this case was very clear: I support decriminalizing all drugs,
as it is stupid to throw depressed and sad people (as only depressed and
sad people use drugs) in prison and ruin their life with a criminal
record. That does not mean that there is any change to the Message which
says clearly that we must not use any drug except for medical purposes.
The same applies to the freedom of expression which must be absolute.
That does not mean again of course that I agree with anti-Jews,
anti-Semites, racists of any kind or anti-Raelians. But by knowing your
enemies or the enemies of your values, you are better equipped to fight
them. With love and respect of course, and with the wonderful sentence
of the French philosopher Voltaire in mind: "I disapprove of what you
say, but I will defend to the death your right to say it".

-- 
-- 
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"Ethics" is simply a last-gasp attempt by deist conservatives and
orthodox dogmatics to keep humanity in ignorance and obscurantism,
through the well tried fermentation of fear, the fear of science and
new technologies.

There is nothing glorious about what our ancestors call history, 
it is simply a succession of mistakes, intolerances and violations.

On the contrary, let us embrace Science and the new technologies
unfettered, for it is these which will liberate mankind from the
myth of god, and free us from our age old fears, from disease,
death and the sweat of labour.

Rael
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