STP Workshop in Bahrain
A workshop on diagnosis and management of sexually transmitted diseases (STD) was organized in Manama, Bahrain, on 6 and 7 December 1998 and was attended by doctors from hospitals and health centres of government as well as private sectors. In his opening remarks, Dr Abdul Wahab Mohammed, Assistant Under-secretary of Public Health at the Ministry of Health, urged doctors to extend their role beyond diagnosis and treatment of patients to their counselling and education about preventive measures. This will help the patients change their behaviour and thus avoid reinfection.

The main objective of the workshop was to train clinicians in provision of acceptable high quality care to persons with STD, in provision of education and counselling for risk reduction, in partner management, in reporting of cases and in integration of STD service delivery into primary health care and reproductive health care. The workshop dealt with various subjects including epidemiology, relationship with HIV, case management, syndromic diagnosis, laboratory diagnosis, health education, counselling, partner management, reporting and provision of STD care within primary health care and reproductive care centres. The facilitators of the workshop included National STD/AIDS Manager Dr Sumaiya AI Jowdar, Head of Health Education Department Dr Amal AI Jowdar, WHO Regional Adviser on AIDS/STD Dr Purushottam Shrestha and WHO Consultant Dr Ahmed Latif.

AIDS Awareness in Lebanese Prisons
A meeting was held between National AIDS Programme and the Lebanese NGO Forum with the aim of increasing AIDS awareness in Lebanese prisons. The objectives of the meeting was to clarify the modes of transmission of HIV/STD in general and in prisons in particular, to define the increased risk of prisoners in getting HIV/STD infection and to identify possible activities for prevention of HIV/STD in prisons. The meeting agreed upon the need to improve the prisoners' awareness about HIV/STD and to carry out a number of activities for reducing the transmission of HIV/STD in prisons. These activities include giving lectures to prisoners, administration staff, security staff, doctors and nurses in order to increase their awareness about AIDS/STD; providing educational and entertainment programmes; providing periodic HIV testing for prisoners; training prison doctors as a part of continuing medical education; improving general situation such as sanitation and reduction in the number of residents in each cell; and keeping the problem of prisons high in the agenda of high officials.

Further WHO Support to Libyan Request
In response to another request for technical assistance from the Libyan Arab Jamahiriya, the WHO Regional Office for the Eastern Mediterranean sent another team of experts to help the authorities in implementing control measures (see EMR AIDSnews Volume 2, Number 4, December 1998). The team, comprising the Regional Adviser on AIDS/STD, a WHO consultant on clinical management of paediatric AIDS and a WHO consultant on laboratory diagnosis of HIV/AIDS, visited the country from 27 December 1998 to 15 January 1999. After further epidemiological investigations, review of management of AIDS in children's hospital and review of HIV testing in various laboratories, the team trained the local staff in clinical management of AIDS and in techniques of HIV testing and quality assurance. The team prepared guidelines on infection control, clinical management and HIV testing procedures and also a plan of action to deal with the current situation.

New Programme Managers
Dr Kamal Alami and Dr Ali Ba Omar have been appointed as the new national AIDS/STD programme managers in Morocco and Oman respectively.

Mother to Child Transmission of HIV
About 14 million women were living with HIV/AIDS in the world at the end of 1998. Of them over 2 million were infected during 1998. Mother to child transmission (MTCT) of HIV can occur from the infected mother to her baby during pregnancy (5%-7%), during labour and delivery (10%-15%) or after delivery through breast-feeding (7%-22%). Nearly 600,000 children were born with HIV infection in the world in 1998, i.e. more than one child per minute. Most of these children were born in sub-Saharan Africa. MTCT is occurring in the Eastern Mediterranean Region of the World Health Organization but on a small scale.

A wide range of factors increases the risk of HIV transmission from mother to child. Maternal factors include advanced immunosupression, advanced clinical disease, high viral load, recently acquired HIV infection and placental barrier disruption (through chorio-amnionitis, placental malaria, smoking). Delivery factors include mode of delivery (vaginal delivery or caesarian section), invasive procedures and prolonged rupture of membranes. Factors after delivery include breastfeeding, cracked nipple and oral lesion in the infant. Reduction of MTCT can be achieved by intervening at any of the stages.

MTCT can be prevented by zidovudine therapy and other interventions. In a study conducted in the USA and France, zidovudine combined with avoidance of breastfeeding reduced MTCT by 67%. In this study, zidovudine was started orally between 14 and 34 weeks of pregnancy, intravenous infusion of zidovudine was given during labour and the neonate was given oral zidovudine for 6 weeks. This is now the standard practice for prevention of MTCT in industrialized countries. A shorter and simpler regimen in Thailand with oral zidovudine from the 36th week of pregnancy and during labour but without intravenous infusion and without treatment of babies reduced MTCT by 51%. Women in Thailand too avoided breastfeeding. Preliminary data from an even shorter study called the PETRA trial, carried out in South Africa, Tanzania and Uganda, showed a reduction of MTCT by 37%. In this study, an antiretroviral drug (zidovudine or lamivudine) was begun at the time of delivery and was continued for both mother and baby for just one week. A majority of mothers in this trial practised breastfeeding, and mothers and babies will be followed for 18 months.

As breastfeeding can lead to MTCT, avoiding breastfeeding reduces the risk of MTCT. Other interventions that are under study for reducing MTCT include micronutrient supplements such as vitamin A and multivitamins, delivery by caesarian section, and vaginal cleansing with topical microbicide such as 0.25% chlorhexidine. Other factors that help reduce the risk of MTCT include provision of good antenatal care including prevention and treatment of anaemia, screening for syphilis and other sexually transmitted diseases and voluntary counselling and testing; avoidance, unless absolutely necessary, of routine episiotomy, artificial rupture of membranes, use of scalp electrodes and fetal blood sampling; and avoidance of other unnecessary invasive obstetric procedures.

Vaccine Trial in Thailand
Thailand's Ministry of Public Health has decided to authorize large-scale human testing of an experimental AIDS vaccine, the first such trial in the developing world. The trial will test the AIDSVAX vaccine developed by VaxGen, Inc., of Brisbane, California, which began a large-scale trial in the United States last June. The vaccine to be tested in Thailand will differ from the product tested in the US, to match the different strains of HIV that exist in Thailand. TheThai trial will involve 2500 volunteers who are at higher risk for HIV infection because of injecting drug use (IDU); the US trial involves 5000 volunteers primarily at risk through sexual transmission.

AIDSVAX is not the first experimental AIDS vaccine, or vaccine candidate, to be tested in humans; since 1987 a number of vaccine candidates have been given to people enrolled in small clinical trials in the US, Thailand, and other countries. But after having been found to be safe and to stimulate an immune response, AIDSVAX is the first vaccine candidate to proceed to large-scale human testing, known as "Phase Ill" or efficacy trials. The only way to know if a vaccine is effective in protecting against HIV infection or disease is by conducting large-scale trials in humans; the first results from the AIDSVAX trials will be available in two to three years.

Thai scientists, national authorities and public health experts have been working with the international research community to define the conditions under which to undertake HIV vaccine research for the benefit of Thai people. The first small-scale HIV vaccine trial was conducted in Thailand in 1994; four other trials have since been conducted. Thai scientists have also been actively involved in the preliminary research that paved the way for the current trial, including the characterisation of the group of volunteers who will participate in the trial and the analysis of the type of HIV that is most prevalent in the Thailand. That information was used to design the vaccine that will be tested in Thailand.