Prevention starting to pay off in some countries

(AP) -- The global HIV epidemic continues to expand, with more than 40 million people now estimated to have the AIDS virus, but in some countries prevention efforts are finally starting to pay off, the United Nations says.

AIDS has killed more than 25 million people since it was first recognized in 1981, making it one of the most destructive epidemics in history. An estimated 3.1 million people died from the virus last year and another 4.9 million people became infected, according to a U.N. update published Monday.

The deaths and new infection estimates were in line with those from last year, when the total number of people living with the virus was estimated at 39.4 million.

However, for the first time there is solid evidence that increased efforts to combat the disease over the last five years have led to fewer new infections in some places, said UNAIDS chief Peter Piot.

Previously improvements had been seen in places such as Senegal, Uganda and Thailand, but those were rare exceptions.

"Now we have Kenya, several of the Caribbean countries and Zimbabwe with a decline," Piot said, adding that Zimbabwe is the first place in Southern Africa, the hardest-hit area, to show improvement.

These are all countries that have invested heavily in safe-sex campaigns and other prevention programs, with the result that prevalence of HIV among the young has declined.

"People are starting later with their first sexual intercourse, they are having fewer partners, there's more condom use," Piot said.

The epidemic also appears to be tapering off in other countries. "We see similar trends in countries in East Africa, but the evidence was not good enough to put in the report," he said.

The most dramatic drops in prevalence have been among pregnant women in urban Kenya, where in some areas the proportion of pregnant women infected plummeted from approximately 28 percent in 1999 to 9 percent in 2003.

In the Caribbean, declines are evident in Barbados, the Bahamas and Bermuda, Piot said.

In Zimbabwe HIV prevalence among pregnant women in the capital Harare has decreased from 35 percent in 1999 to 21 percent in 2004.

"I absolutely believe we are on a roll," added Dr. Jim Kim, HIV chief at the World Health Organization. "Everyone is sort of jumping on the bandwagon. I think there's been a fundamental change, even in the past one year, in all the efforts in HIV."

There's a new energy, Kim said, and much of that comes from the recent availability of HIV treatment in the developing world.

About 1 million HIV patients in the developing world now are on treatment. While that is just a small fraction of the people needing treatment, the availability of drugs has meant that people see a point to getting tested for the virus, which is crucial for prevention efforts. About 300,000 deaths were avoided last year because of treatment, the report said.

"As much as possible, we've got to get that energy into prevention as well," Kim said.

So far this year the world has spent slightly more than $8 billion on tackling HIV in the developing world. That was a big increase from the $6 billion spent last year but was still far short of the need.

UNAIDS estimates that $9 billion will be spent next year but say $15 billion will be needed.

The epidemics continue to intensify in southern Africa. Growing epidemics are under way in Eastern Europe and in Central and East Asia. Five years ago, one in 10 new infections were in Asia. Today the number is one in four or five.

China, Papua New Guinea and Vietnam are facing significant increases. There are also alarming signs that Pakistan and Indonesia could be on the verge of serious epidemics, the report said.

Intravenous drug use and commercial sex are fueling the epidemic in Asia, where few countries are doing enough to inform people about the danger of such behavior, the report warned.

Worldwide, less than one in five people at risk of becoming infected with HIV has access to basic prevention services. Of people living with HIV only one in 10 has been tested and knows that he or she is infected.

 

WHO sorry for missing AIDS target

(Reuters) -- The World Health Organization apologized on Monday for missing its target to get 3 million people in poor countries on life-saving AIDS drugs by the end of 2005.

Dr Jim Yong Kim, the director of the WHO's HIV/AIDS department, admitted that the WHO had not moved quickly enough to meet its ambitious "3 by 5" target.

"I have to say that I'm personally extremely disappointed in myself and in my colleagues because we have not moved quickly enough -- we have not saved enough lives," Kim told the BBC.

The WHO and the Joint United Nations Program on HIV/AIDS (UNAIDS) had hoped to provide 3 million of the 6 million people in poor countries with treatment but the real acceleration in numbers they had hoped for did not materialize.

The exact number of HIV/AIDS sufferers on treatment will be announced early next year. In June, Kim said about 1 million people in poor countries were receiving the drugs.

"All we can do is apologize," he said less than a week before World AIDS Day on December 1.

Although the 3 million mark will not be reached, Kim said he didn't think the initiative had failed because the program had increased the number of people on antiretroviral drugs and had saved lives.

Because of the "3 by 5" initiative, many more countries had joined the program and provided access to AIDS drugs.

In sub-Saharan Africa, the region worst affected by HIV/AIDS, about half a million people were receiving treatment by the middle of 2005. Although it was a three-fold increase in the last year, it was still only about 15 percent of those who need it.

People on treatment in Asia had risen from 55,000 to 155,000 since June 2004, while in eastern Europe and central Asia people on treatment nearly doubled in a year to 20,000, according to the "3 by 5" update report issued in June.

Kim said before the initiative there were no targets for treatment or for preventing the spread of HIV/AIDS, which killed 3.1 million people in 2005.

More than 40 million people worldwide are living with HIV/AIDS, according to latest figures from UNAIDS.

 

New hope, old challenges in AIDS fight

 (CNN) -- Decades after the first reported AIDS cases, public awareness, medical progress and hope have by and large replaced fear, reproach and mystery about the disease in the American consciousness.

The image of HIV, which can develop into full-blown AIDS, has evolved significantly since June 5, 1981, when the Centers for Disease Control and Prevention noted a deadly form of pneumonia that was affecting gay men.

In the United States, in particular, outreach efforts have helped many understand that being HIV positive is no longer a death sentence. Nonetheless, stigmas and ignorance exist in some communities, dangerous lifestyles are common in others, and AIDS victims still face enormous difficulties.

"It's 20 years into the epidemic. You'd think this wouldn't be going on anymore," said Dr. Perry Halkitis, the director of New York University's Center for HIV/AIDS Educational Studies and Training.

By the mid-1980s, thousands had died from the disease, while many others lived with it despite public persecution and slim prospects for a cure.

The stereotype that AIDS struck only gay men slowly faded. Ryan White, a teenager who acquired the ailment from a blood transfusion, earned acclaim for his public struggle. In 1991, NBA great Magic Johnson revealed he had become HIV positive through heterosexual sex. HIV/AIDS "drug cocktails" improved through the 1990s, as did survival rates. Today, the United States ranks 67th in the world in HIV/AIDS prevalence among adults, with 29 of the top 30 countries located in Africa.

But the disease hasn't gone way. About a million Americans are HIV positive -- about half are unaware they are infected or are unable to get proper treatment -- and 14,000 die from HIV/AIDS annually, according to official reports. After a steady decline, the estimated number of annual new AIDS diagnoses leveled off at slightly more than 40,000 in the late 1990s and early 2000s.

Although African-Americans and gay and bisexual men are most likely to be infected, AIDS affects almost every segment of the population.

"There's still that misperception that people are only at risk for HIV if they're gay or if they use drugs or if they're highly sexually active with multiple partners," said Dr. Ron Valdiserri of the CDC. "The reality is, it only takes one partner to become infected."

Although not considered as much of an imminent threat as it has been previously, AIDS remains a prominent issue. Celebrities, dignitaries and advocates have devoted time and money to educate the public and to help those suffering from the disease, while scientists try to create a vaccine.

"There is nothing more important in this world than this," said actress and activist Ashley Judd. "Nothing."

Blacks, gays at high risk
African-Americans comprised less than 13 percent of the U.S. population in 2002, but half of new AIDS cases that year. And black women were 23 times more likely than white women to contract HIV, while black men were nine times more likely than white men.

Experts say several factors contribute to the discrepancy. In 2002, a quarter of African-Americans were living in poverty, meaning many lack health care and HIV-prevention education. Insufficient medical treatment also contributed to blacks' lower survival rates: Only 55 percent of those infected live another nine years, less than any other racial or ethnic group.

African-Americans also have higher rates of substance abuse and sexually transmitted diseases than the national average. Many are slow to admit or ask about drug use, homosexuality and other issues that put them at high risk for AIDS, the CDC reports.

"We don't have open and honest discussions about the sexuality in our communities, and what we get out of that is people being unable to claim the truth of their lives," said Phil Wilson, director of the Black AIDS Institute.

The homosexual community is another group disproportionately affected by AIDS. In the mid-1980s, half of the gay men in New York and San Francisco, California, were HIV positive. The U.S. gay community took action, with condom use rising and the new infection rate plunging.

Yet that momentum has halted in recent years. HIV diagnoses among the group soared 17 percent between 1999 and 2000, compared with 7.3 percent for all men during that same time. Just less than 15 percent of gay and bisexual African-Americans have the disease.

"Safe-sex fatigue set in, and there was also a rise in complacency in what living with HIV actually meant," said Peter Staley, an AIDS activist who was diagnosed with HIV in 1985. "There are young guys that aren't scared of it anymore."

Young and old affected
Although certain populations face higher risks, AIDS touches everyone from school-age children to people in nursing homes.

People under 25 account for half of new HIV infections in the United States, or about 20,000 annually, according to the CDC. All but a handful of those are 13 or older, this despite extensive AIDS-education efforts in schools and in youth-oriented media, like MTV.

A 2004 Kaiser Family Foundation national poll of 15-to-17-year-olds found a high degree of knowledge about safe-sex methods, and 71 percent of sexually active teens said they use contraception or protection (with condoms the most common option) "all of the time."

"We're the ones that are the most educated, and we're still the ones going out there getting infected all the time," said Lisel Christian, a 20-year-old college student who is HIV positive.

Just more than half of teens reported talking to parents (and one-third to their doctor) about HIV/AIDS. Many teens said they keep to themselves about sex because they felt embarrassed or fearful, a 2002 KFF survey reported. Some students said the media spread mixed messages.

"It's really confusing to know what message you're supposed to believe, because there are people that are maybe, like, 16 years old having sex on TV ... Then they show safe-sex commercials," said Kelly Dearth, a senior at Wheeling Park High School in West Virginia. "It's like, what am I supposed to be doing?"

AIDS is also an issue on the other side of the age spectrum. People are living longer, and drugs like Viagra, Cialis and Levitra have extended the sex lives of people in their 70s, 80s and 90s, said Jolene Mullins of the Broward County, Florida, Health Department.

"We were really brought up in ignorance," said Miriam Schuler, 85, known as the "Condom Grandma" for her safe-sex advocation efforts. "We knew only that if we got married, you use a condom to prevent pregnancy and that's all. We didn't have that terrible disease."

Those who are 50 and older make up about 15 percent of all AIDS cases in the South Florida counties of Miami-Dade, Palm Beach and Broward, well above the national average of 11 percent for people in that age group.

Mullins said actual infection rates among seniors are likely much higher, because doctors mistake many early HIV symptoms -- rashes, fevers, weight loss, forgetfulness -- as simply signs of aging.

Fighting complacency

Some fear that inroads against AIDS -- and the sense it is no longer viewed as a medical "emergency" -- may spawn complacency in the United States. Yet HIV/AIDS outreach efforts remain very much in the spotlight.

Television and print public service announcements featuring sports and music stars, and initiatives led by world leaders such as former President Clinton and ex-South African President Nelson Mandela, have emphasized treating and preventing HIV/AIDS. The charitable foundation of Bill Gates -- the world's richest man, according to Forbes -- has given hundreds of millions to AIDS-related efforts.

"If we do this work now, we may save 10, 15 million lives," said actor Richard Gere, who donates $100,000 annually to run an orphanage for HIV-infected children in India. "It gives you a lot of focus. I mean, how many things in your life can you do that have that kind of impact?"

U.S. funding of AIDS-related initiatives has surged from $100 million in 1984 to $18.5 billion in 2004. Under the Bush administration, more funds have been focused on fighting AIDS internationally, with money spent on prevention dropping and research holding steady.

What is the future of AIDS in the United States? This summer, scientists tempered predictions that a vaccine could be a few years away, saying it could take much longer.

"The world is inching towards a vaccine," Seth Berkley, president of the International AIDS Vaccine Initiative, told the Reuters news agency.

In the meantime, outreach efforts continue -- to help those suffering from the disease and to inform the public how to prevent its further spread.

"The day will come when all of us will be asked a question, what did you do?" said Wilson of the Black AIDS Institute. "People were dying, people were getting sick. It didn't have to happen, what did you do?"


Model For Financing of Costly Vaccines

 The Wall Street Journal, April 26, 2005

Next month, hundreds of African infants will get an experimental vaccine against malaria in a medical trial that could foster a multibillion-dollar collaboration of science, philanthropy and market savvy.

Under two new funding strategies championed by Microsoft Corp. founder Bill Gates and Britain's finance minister, Gordon Brown, rich nations and their private-sector partners for the first time would jointly guarantee the provision of vaccines against the worst scourges afflicting the developing world.

They are stepping in where market mechanisms have failed. While older vaccines for diseases like mumps and measles are more widely and cheaply available, vaccines for malaria, tuberculosis and AIDS, the developing world's top killers, are so risky and costly to bring to market that little progress has been made in these areas. The malaria vaccine about to be tested has been under development for two decades -- and at one point it was nearly abandoned. The annual death toll for AIDS, TB and malaria totals at least six million.

The new funding tools are aimed specifically at this market failure. In one approach, donor governments would guarantee that a company that produced a cutting-edge vaccine for poor countries would receive market-rate prices long enough to recoup development costs. This mechanism, proposed earlier this month, is called an advance-purchase contract.

The other strategy consists of rich countries, for the first time, floating government bonds geared specifically to supplying poor countries with available vaccines now and new vaccines later. Through a proposed International Finance Facility for Immunization, the billions of dollars expected to be raised would greatly expand the distribution of existing life-saving vaccines for diseases like polio and hepatitis, and ensure that newer vaccines reach those who need them.

Of course, the first battle -- coming up with vaccines for the worst diseases -- is still being fought. Meanwhile, there is concern among aid groups that the new funding proposals will divert resources from proven tools, such as mosquito nets.

Malaria is one of the scourges targeted by the Bill and Melinda Gates Foundation set up by Mr. Gates and his wife, Melinda. The mosquito-borne disease, long kept in check in affluent nations with drugs and pesticides, kills nearly two million people in Africa every year, and claims additional victims elsewhere. Mr. Gates has steered his $28.8 billion foundation toward fixing such global-health inequities.

The focus of his current push is the malaria vaccine being tested next month. The vaccine program almost died in a corporate restructuring in 1999. But a Gates-funded group gave GlaxoSmithKline PLC's GSK Biologicals unit in Belgium a $10 million grant to fund the study for toddlers, and is negotiating for further grants to help fund the coming study in infants.

Malaria is transmitted by mosquitoes infected with a parasite that, once injected into humans, passes through four life stages in the bloodstream and liver before bursting from red-blood cells to ignite fever, chills, weakness, anemia, brain damage and death.

Centuries of drugs from quinine bark through standard antibiotics to the now preferred artemisinin drugs have proved useful. But malaria recurs every wet season, causing 300 million to 500 million cases world-wide. Drug resistance mounts relentlessly, and recurrent supply shortages limit treatment programs.

Preventive vaccines have faced daunting hurdles. Malaria's four stages complicate vaccine design, says Gates Foundation scientist Regina Rabinovich: "The parasite is way too smart."

In 1987, Joe Cohen, leader of the malaria project at GSK, began focusing on a vaccine that would boost antibodies but also stimulate special white blood cells, including "killer cells" that take out the human cells infected by malaria parasites.

Researchers volunteered to be guinea pigs. GSK Vice President W. Ripley Ballou -- then working at Walter Reed Army Institute of Research near Washington, D.C. -- vaccinated himself with an early prototype. After becoming infected by lab mosquitoes, he got malaria with a fever of 104. "I've never been so sick in my life," he says. But one volunteer was protected from malaria, offering a shred of hope.

Dr. Cohen's team analyzed malaria's deadliest strain, Falciparum. He selected a protein from the form injected by mosquitoes. Then he fused genes from this protein with hepatitis B virus. This rallied broader immunity by stimulating production of both antibodies and killer cells. The team christened the vaccine "Mosquirix," which combined the word mosquito and part of Rixensart, the Belgian city where the GSK unit has its headquarters.

By 1996, the vaccine was protecting "a significant number of volunteers in the lab," Dr. Cohen says. "It was a breakthrough." In 1998, the vaccine moved into field tests in adults in Gambia. But in 1999, amid skepticism about markets, the malaria research was slated for elimination. Dr. Cohen learned of the restructuring and called his boss on a Sunday morning, seeking a last-minute reprieve. He proposed funding his vaccine with outside grants, an unusual move for a corporation. The unit's president, Jean Stephenne, backed the idea.

Several scientists and public-health experts sent a seven-page application to the Gates Foundation. In June 1999 of that year, the foundation gave an initial $50 million, later raised to $150 million, to launch the Malaria Vaccine Initiative in Seattle, which in turn gave $10 million to GSK.

That money funded clinics, training and salaries for the largest such malaria-vaccine study in Africa to date: a controlled clinical trial in more than 2,000 Mozambique toddlers aged 1 to 4 that started in April 2003.

In Manhica, Mozambique, mothers lined up with their toddlers to receive either the malaria vaccine or a "control" vaccine, such as one for hepatitis. The malaria vaccine group had 30% fewer first attacks, 58% fewer deadly cases.

Touring Mozambique in September 2003, Mr. and Mrs. Gates visited a village where nearly half the children die of malaria. "I visited with a baby suffering from cerebral malaria, one of the most severe forms of the disease, and I didn't know whether that baby was going to be alive the next morning," Mr. Gates said in an e-mail.

While the vaccine work moved forward, work on funding was gathering momentum. The traditional vehicle for lowering medicine costs to the developing world is tiered pricing: Consumers in wealthy nations pay higher prices, subsidizing discounts in poor nations. But malaria vaccines don't have sales prospects in the developed world.

Seeking solutions, Gates Foundation officers had brainstormed in June 2003 with British finance experts at the Wilton Park Conference, sponsored by the U.K. government. Mr. Brown and his team were proposing a $50 billion International Finance Facility for general African aid.

The Gates Foundation's senior economist, Rajiv Shah, seized on the IFF concept to suggest a special pilot IFF just for vaccines. He proposed an IFF for Immunization that would let countries go to the international bond market to obtain funds to speed up the purchase of existing vaccines and later of new vaccines. The Gates and Brown teams, with the Global Alliance for Vaccines and Immunization, jointly proposed the $4 billion as a war chest.

The idea drew more support after Glaxo published the results of the Mozambique test in the British medical journal Lancet last October. Mr. Brown endorsed the IFF for Immunization and advance-purchase contracts. He urged leaders of the Group of Eight industrialized nations to act on the proposal at their summit meeting in Gleneagles, Scotland, this coming July, and he pledged ?1 billion (about $1.9 billion) from the U.K.

Mr. Brown visited GSK's Mozambique vaccine test site earlier this year, and conferred with the Gates Foundation and Glaxo Chief Executive J.P. Garnier about making an advance-purchase contract available if the infant studies prove successful.

Mr. Gates lobbied French President Jacques Chirac, German Chancellor Gerhard Schr? and other leaders in private meetings and at the World Economic Forum in Davos, Switzerland, in January. There he said $4 billion "would save five million lives for less than $1,000 a life."

France, Germany, Italy, Sweden, Canada and others backed the IFF. The U.S. didn't, saying it clashed with Congress's budget cycles.

Messrs. Gates and Brown also were pushing the advance-purchase contracts for the malaria vaccine. The idea was developed by Harvard economist Michael Kremer and the Center for Global Development, a Washington think tank supported by Mr. Gates.

Such contracts would assure companies of a substantial return on their investment by creating a market of $3 billion or more for malaria vaccines. They would offer companies $15 to $25 for a three-shot regimen for the first 200 million people. Then the price would drop to $1 or $1.50 a person.

The funding tool is gaining support in Washington. In its 2005 report, President Bush's Council of Economic Advisers called advance-purchase contracts for malaria vaccine "particularly promising" because they reward competition.

Next month, GSK tests advance to the ultimate target group: 10-week-old infants. In Mozambique and Tanzania, 600 to 800 infants will get malaria vaccine with their routine shots. If Mosquirix protects them -- a delicate feat due to their immature immune systems -- tests will expand to more countries. If these succeed, GSK says Mosquirix could be available in five years.

Without the Gates money, "it is fair to say we would not be where we are today. It would be difficult...to sustain the cost," says Glaxo's Mr. Garnier. Commercializing the vaccine would top $1 billion. GSK's vaccine-unit chief, Mr. Stephenne, says, "We need these incentives."

Some aid groups are less bullish on the malaria-vaccine funds. Doctors Without Borders malaria expert Christa Hook says she fears they would divert resources from proven tools like drugs and bed nets. Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, says the vaccine would produce at best 50%-60% efficacy and may be closer to 10 years away. "We need to do a lot more of what we know how to do," he said.

 

U.N.: HIV cases on the rise worldwide

 GENEVA, Switzerland (CNN) -- About 70 percent of new AIDS cases are in hard-hit sub-Saharan Africa, according to a new U.N. report on the extent of the global epidemic. 

More than nine out of 10 of the estimated 3.1 million people who will die this year of HIV/AIDS live in either sub-Saharan Africa or in south or southeast Asia, the two regions hardest hit by the epidemic, according to the report, released Tuesday by the World Health Organization and the Joint U.N. Program on HIV/AIDS. 

Of those who will die from HIV/AIDS this year, 610,000 are younger than 15, and almost half are women, the report said. The two most populous countries in the world -- China and India -- are both facing "serious, localized epidemics," with more than 1 million Chinese and 4 million Indians infected with HIV. 

But the world's fastest-growing HIV/AIDS epidemic is happening in Russia, Eastern Europe and Central Asia, where there will be an estimated 250,000 new infections and 25,000 deaths, according to the report. Most of the infections are attributable to a sharp increase in people who inject heroin and other drugs, and most of those infected are younger than 30, the report found. 

Far-reaching effects

The report found that the impact of HIV/AIDS in sub-Saharan Africa, where nearly 9 percent of the adult population is infected with HIV, is contributing to a food crisis in the region, as illness and death impact the ability of people to grow food or earn the money to buy it. At least six countries dealing with famine -- Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe -- have high rates of HIV in their populations. 

While drought, political turmoil and misguided policies are contributing to famine, the report said HIV/AIDS is also a major factor. 

"Households are able to achieve food security when they can produce sufficient amounts of nutritious food, earn enough cash income to purchase food, sell or barter assets for food in hard times and rely on social support networks for assistance," the report said. "The HIV/AIDS epidemic is eroding each of these coping methods." 

Unable to cope, the report found that people often adopt survival strategies that put them at greater risk for infection and death, including women and children who barter sex for food and people who migrate to urban slums where they lack access to health care. 

Worst still hasn't passed

Despite initiatives by Western countries, drug companies and African nations themselves to increase the availability of antiviral drugs to prolong the lives of people living with HIV, only a "tiny fraction" of those infected with HIV are receiving the drugs, the report said. As a result, the AIDS death toll in Africa is expected to continue rising until the end of the decade. 

"The worst of the epidemic clearly has not passed," the report said. 

In four southern African countries -- Botswana, Lesotho, Swaziland and Zimbabwe -- more than 30 percent of the adult population is infected, the report said. By contrast, in North America, less than 1 percent of the adult population is HIV-positive. 

In Africa, unlike much of the rest of the world, the majority of HIV-positive adults -- 58 percent -- are women who acquired HIV through sex with infected men. By contrast, in North America, about 80 percent of HIV-positive adults are still men, according to the report, although the percentage of women has been rising in recent years. 

Other findings

Despite the mounting toll of infection and death, the report did find some encouraging developments:

• In Cambodia, the Asian country with the highest prevalence of adult HIV infection, high-risk behavior appears to be decreasing and infection rates stabilizing. The report attributes the improvement to a campaign to get sex workers to use condoms consistently.

• In South Africa, which has the world's largest HIV-positive population, there has been a marked drop in the number of young pregnant women testing positive for HIV -- 15.4 percent compared to 21 percent in 1998. 

• In Uganda, recent HIV infections appear to be on the decline in several parts of the country, which are attributed to HIV awareness efforts. 

• HIV prevalence among pregnant women has stabilized and may even be on the decline in the Dominican Republic, where about 2.5 percent of the population is estimated to be infected. Increased condom use among female sex workers and a decrease in the number of sexual partners among men are being credited for the improvement.

 

Report: 15 million AIDS orphans 

 Tuesday, July 13, 2004

BANGKOK, Thailand (Reuters) -- The AIDS epidemic has robbed 15 million children of one or both parents and reversed a trend toward fewer orphans driven by better health and nutrition, a U.N. report said on Tuesday.

With HIV infection rates rising and the incurable disease taking 10 years to kill without treatment, an estimated 18.4 million children will have lost at least one parent by 2010, according to the UNICEF report released at the 15th International AIDS Conference.

"It is a tidal wave of children who have lost one or more of their parents," Carol Bellamy, executive director of UNICEF, the United Nations children's agency, told Reuters.

"Fifteen million globally, close to 12 million in sub-Saharan Africa alone," she said. "It has the possibility of destabilizing societies quite dramatically."

Without the AIDS epidemic, which has already killed 20 million people worldwide and infected 38 million, the numbers of orphans would be falling because of better health care and nutrition. AIDS has reversed the trend.

Much of the AIDS meeting that began on Sunday has been focused on money, improving universal access to life-prolonging drugs and wrangling over whether abstinence or condoms is the best way to prevent new infections.

But children's activists argue that the plight of orphans and vulnerable children is not getting the attention it deserves within the overall AIDS effort.

"In some ways orphans are one of the orphaned issues at this conference," said Dr Joanne Carter, legislative director of RESULTS, an international anti-hunger and anti-poverty group.

"It's clear that what is left in the wake of the AIDS pandemic is these kids. These kids are the futures of their society and they have been largely forgotten by the global community," she added.

U.S. Congresswoman Barbara Lee, a Democrat from California and the only member of Congress at the week-long meeting, described the orphan crisis as "mindboggling."

"The world cannot stand by and watch this occur," said Lee, the author of legislation to help orphans and vulnerable children which has passed the U.S. House of Representatives and is attracting support in the Senate.

In Asia, where the AIDS epidemic began relatively recently and HIV prevalence is still low, the number of orphans has dropped since 1990. But if HIV expands, as many experts fear it will, so too will the number of orphans.

More than any other cause of death, AIDS is more likely to deprive children of both parents. They face discrimination because a parent has died of AIDS, abandonment if relatives cannot or will not care for them, and the
responsibility of caring for younger siblings. They may be infected themselves.

They may also be deprived of guidance and education and will be more vulnerable to violence and exploitation.

The UNICEF report calls for more funding for programs to help families and the community cope with the crisis and to ensure there is education, health care and legislation to protect orphans.

"Much too little is being done," said Bellamy.

"Simple things could make a big difference when it comes to AIDS orphans and could give these children an opportunity for the future."

Medicins Sans Frontieres (MSF), a leading medical and humanitarian organization, said treating children with HIV/AIDS was an uphill battle because drugs and diagnostic tests have not been adapted for them.

"We need to pay more attention to them. They are not just small adults. There are specific issues in terms of diagnosis and specific issues in terms of treatment," the MSF's David Wilson told the conference being attended by more than 17,000 people.

Geneva-based MSF pharmacist Fernando Pascual said drug companies were ignoring the treatment of children, for whom there are none of the fixed-dose combinations available to adults.

"They will not produce formulations for children unless there is pressure from the international community," he said.

 

HIV – AIDS Statistics

 3.1 million people died of AIDS (Acquired Immune Deficiency Syndrome) last year.

39.4 million people globally are now living with the human immunodeficiency virus (HIV), the increase largely due to a surge in the rate of infection in Eastern Europe and Asia.

AIDS a Woman’s Disease

Half of those affected with HIV are women, an increasing proportion. Over the past two years, the number of females living with the disease has increased in every region of the world. *

* Women are biologically more susceptible to AIDS, with male-to-female transmission during sex twice as likely as female-to-male transmission. But cultural factors also play a significant role. In Africa and Asia, many women find it difficult to persuade partners to practice safe sex. 

**The increasingly female face of HIV in the world has major implications because it means that treatment and prevention programs must focus on women if the world wants to stop the epidemic. Often, when a woman becomes a widow, she loses everything and is pushed to extreme poverty and forced to sell her body. Additionally, new laws need to be passed to protect women against male sexual violence within marriage. Many women cannot refuse to have sex with their infected husbands. Also, a disproportionately small number of women are receiving anti-H.I.V. drugs. Even if their husbands can afford the anti-retroviral drugs, many refuse to buy them for their wives. 

AIDS in various African nations

A UN Aids study shows that the problem is especially acute in Sub-Saharan Africa. Nearly 60 per cent of those living with HIV are women**, and among 15-24-year-olds the figure rises to 76 per cent.

Life expectancy has dropped below 40 years in nine African countries - Botswana, Central African Republic, Lesotho, Malawi, Mozambique, Rwanda, Swaziland, Zambia and Zimbabwe. 

Nigeria was rated the country with the third highest number of people living with AIDS, after South Africa and India.

Sub-Saharan Africa, with just over 10 percent of the world's population, is home to more than 60 percent of all HIV positive people.

The good news for Eastern Africa: The report shows a significant decline in infections in Kenya, Uganda, Ethiopia and Burundi. 

AIDS in Asia

Asia may soon surpass sub-Saharan Africa as the world's worst hit region. The UN has warned that China, India and Indonesia are now at grave risk.

India, 5.1 million people were living with the AIDS-HIV virus at the end of 2003, and the UN warns that serious epidemics are underway in several states of the country.

On the upside, several Asian countries such as the Philippines and Pakistan have extremely low HIV infection rates. The UN says these countries have a golden opportunity to pre-empt serious outbreaks.

Thailand has been singled out as a country that has a well funded, politically supported and pragmatic response to control the epidemic.

Russia: At the end of 2003, 860, 000 people were living with HIV in Russia, making it the highest number in Europe.

Treatment

Distribution of the anti-retroviral drugs, which can hold HIV at bay, is widening, but slowly. Around 440,000 people in poorer countries now have access to this medication, yet they account for only 10 percent of those currently in need.

 

AIDS 

 May 27th 2004 
From Economist.com

In the more than 20 years since it first surfaced, AIDS has taken an enormous toll, particularly in sub-Saharan Africa. For hard-hit countries, the economic impact has been severe, and many children have been orphaned. In much of the developing world, prevention and treatment efforts have been piecemeal, and hampered by ignorance, complacency and stigma. 

In hard-hit southern Africa—where AIDS has exacerbated famine—progress is being made in some countries, but South Africa's efforts have remained weak (a new program to provide anti-retrovirals may be a welcome change). 

China and Russia also still seem to be in denial about their growing problems with the disease. And the epidemic in India, which along with China accounts for a third of the world's population, could grow to African proportions if it is not brought under control soon.

Vaccines seem some way off; researchers announced in February 2003 that the first big trial of a vaccine had failed. Anti-retroviral drugs, which limit the disease and make it less contagious, have done much to extend lives in rich countries, and have also been made available in countries such as Botswana (which is now implementing routine AIDS testing to better identify those who need help). 

Though on the whole the developing world has been left behind, this is starting to change: global treatment efforts are becoming better co-ordinated and funded. In January 2002 the UN set up a global AIDS fund to combat the disease, promising to improve treatment for the poor as well as the rich. 


AIDS IN INDIA (Five-Part Series)

South Asia's smoldering threat
Sabin Russell, Chronicle Medical Writer
Sunday, July 4, 2004

Udaipur, India -- On a mat on the hard stone floor of her tiny home in rural Rajasthan, a 34-year-old widow lay unconscious, gasping for breath, dying of AIDS.

Her name was Mohini Bai, and until recently, she worked in a women's health clinic in her village of Kuncholi, 30 miles from the nearest city. Dry hills ring the village, in a region used as a rugged backdrop for India's moviemakers. Villagers here scratch out a living from small plots of soil, where wheat is still cultivated by hoe and harvested by hand.

While Mohini Bai's 11-year-old son flitted nervously in and out of the room, her sister-in-law knelt at her pillow, tearfully fanning away flies and the oppressive heat with a piece of cardboard. No AIDS drugs were available for Mohini Bai. She squandered her meager savings on local faith healers, who also revealed to her neighbors the 5-year-old secret of her infection. 

Within days of slipping into a coma, she was dead. 

Hers was one more death to be tallied on the subcontinent of India, where AIDS has been silently spreading for more than a decade, and where world health experts believe the pandemic may take its next terrible turn. 

As AIDS was exploding in Africa during the 1990s, it was smoldering in India -- home to 1 billion people, the second most populous nation on Earth. Although less than 1 percent of its population has contracted the AIDS virus, there are already nearly 5 million infections in India. Only South Africa has more. 

Although most AIDS patients in India today are men -- three men for every woman with the disease, according to national statistics -- many health experts suspect this will change. 

In Africa, women are disproportionately afflicted with AIDS, and it is women like Mohini Bai who will be most at risk should AIDS take a similar course in India. 

AIDS prevention failed in Africa, according to Adrienne Germain, president of the International Women's Health Coalition in New York. 

"Now the AIDS epidemic there is female. The same thing will happen in India, only it will be worse," said Germain, who has spent years on the subcontinent. 

Looking to India 

When the 15th International AIDS Conference convenes next week in Bangkok, world attention will focus on the threat the virus poses to Asia. In the view of many health experts, the future course of AIDS in Asia will be set by India's example. 

Will India become the next Africa? Or will it follow the example of Brazil -- a developing country that aggressively pursued AIDS prevention and treatment, and kept the epidemic under control? 

Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, views India as "the decisive battleground" in the fight against AIDS, given its position as global trading center in the heart of the world's most populous region. 

"If India succeeds, the pandemic can be stopped dead in its tracks,'' he said. "If it fails, then AIDS spreads to China, and the rest of Asia, and becomes the biggest problem of the 21st century.'' 

A wildly diverse land of 35 states, 16 official languages and 1,600 mother tongues, India is a paradoxical place. Oxcarts carrying sun-dried dung for cooking fires share roads with computer engineers chatting on cell phones, and destitute pavement dwellers set up ramshackle homes at the doorsteps of the rich. 

Women hold a distinctly second-class status in the cultural hierarchy of India, yet the society brims with the leadership of brilliant women and, in this spring's national election, would have chosen Sonia Gandhi as prime minister had she not turned down the job. 

A dry patch of northwest India that borders Pakistan, Rajasthan is considered a so-called low prevalence state, with less than one-half of 1 percent of its 56 million inhabitants infected with HIV, the virus that causes 

AIDS

But the true extent of the disease there is unknown. Researchers rely on HIV tests of pregnant women to map the course of the epidemic, but in Rajasthan -- one of India's poorest states -- very few pregnant women are ever tested. Mohini Bai was diagnosed only after her husband died of AIDS. 

India does not yet have an African-style epidemic -- where 1 in 3 adults in nations such as Zimbabwe and Botswana is infected with HIV -- but the ingredients for such a catastrophe are well in place. 

Rural susceptibility 

A heterosexual epidemic has seeded itself in at least 50 of 595 districts throughout India. As in Africa, there are high HIV infection rates among female prostitutes, most of them impoverished villagers drawn to a thriving sex trade in the cities. India and Africa each has highway networks plied by truckers with worrisome infection rates. Both have large contingents of male migrant laborers who can carry the virus from urban areas, where they work, to rural villages, where their wives and children live. 

Three out of four Indians dwell in rural areas, where literacy rates are low and modern health care is bare-bones at best.

The unequal treatment of women in India mirrors that found in Africa. Subservient to men in the workplace and the bedroom, married Indian women run a higher risk of HIV than their single counterparts. 

Dr. Geeta Sodhi, a pediatrician and director of Swaasthya, a New Delhi organization focused on women's health issues, explained that in India, arranged marriages are the norm, and a woman's role is to deliver a male child to the family. She must handle household chores, and in rural areas, work the fields. As such, women have little power to negotiate safer sexual practices such as condom use and can be physically abused if they seek it.

According to Sodhi, India's population control policy, which promotes sterilization of mothers as young as 20 years of age, can increase the risk of HIV infection. "What little power women have to negotiate condom use is swept away,'' she said. 

India's National AIDS Control Organization, a government agency, has conservatively estimated that the number of HIV infections will grow to 9 million by 2010, and that 1.9 million will have died. But outside groups paint a bleaker portrait. A report for the CIA by the National Intelligence Council -- a Washington, D.C., think tank -- forecasts infections could jump to 25 million in the same period.

Private crusade 

With annual public health spending on AIDS in India a paltry 11 cents per person, it falls on an army of private doctors, social workers and charitable organizations to carry out India's most effective AIDS prevention activities. 

Drs. Sharad and Kirti Iyengar met in medical school and decided early in their careers that they could make a difference by setting up women's health clinics in underserved rural areas. They settled in Udaipur, a Rajasthan tourist city of 300,000 surrounded by a vast web of farming villages. 

In 1997, they started their first clinic in Kuncholi, two hours by car into the Aravalli Mountains, in the valley of the winding Banaas River. 

In every village, the tall, thin women of the Bhil tribe walk barefoot along the roadside, draped in traditional saris of brilliant blues, greens, yellows and pinks. Seemingly dressed for a party, they may be tending goats or working the wheat fields. Women literally do the heavy lifting there, walking miles with heavy pots of water, sacks of rice or bundled firewood balanced on their heads. 

Meanwhile, some 40 percent of the young men in Rajasthan quit their villages by their late teens for work in India's big cities. The Iyengars have set up a program to boost the AIDS awareness of these young workers, so they will be less likely to come home infected with the virus. 

One of those young men, 19-year-old Kailash Mehkua, donned his best shirt on a sweltering April morning for a long bus and train ride to Bombay, where he will spend a year working for a Japanese pen company. The position had been arranged by the Iyengars' Action Research & Training for Health program, which twinned a jobs-training program with classes on human sexuality and AIDS prevention. 

"I learned how to keep a bank account and learned about family planning, '' Mehkua said. "I learned how AIDS develops and what happens if someone has it." He acknowledged that "only a few boys" in his village are similarly aware of the disease.

Vulnerable female class

The young women in Rajasthan villages tend to stay put. Often growing up in a state resembling house arrest, they are forbidden to leave their homes without a companion until a marriage is arranged for them, often in their early teens. By the age of 19, half the girls in the village have had at least one pregnancy. Many are mothers before they turn 15. 

Women living in these conditions are highly vulnerable to AIDS. Without the ability to negotiate safer sex, millions of Indian women must trust their health to the fidelity of their husbands. 

That trust may be misplaced. Mere discussion of sex is frowned upon in this traditional society, yet nearly 20 percent of the women test positive for sexually transmitted diseases at the Iyengars' reproductive health clinic in Kuncholi. 

Such findings give doctors here an uneasy feeling. 

"I think that HIV infection here is much more common than believed,'' said Kirti Iyengar, who is an obstetrician/gynecologist. "But because of the lack of testing, we just do not know.'' 

AIDS tests are available in Udaipur, at a cost of about $7, but at that price, few will ever have their blood screened. For most people in this rural zone of poverty, $1.15 a day is a typical wage. 

"The test is expensive, and the person also has to travel for it. Confidentiality is poor,'' Iyengar said. There is also no incentive to get an AIDS test where there is little prospect of treating the disease. In such circumstances, a positive test is merely a death sentence. 

Victim of circumstance 

It is a sad irony that Mohini Bai was employed as a patient attendant at the Kuncholi clinic. For five years, the Iyengars were among just a handful who knew that her husband had died of AIDS and that she had tested positive.

Since her health took a turn for the worse a month earlier, Mohini Bai had been to visit hospitals twice in Udaipur. She spent five days at a private hospital, at a cost of about $7 a day, taking up most of her month's wages. 

She also visited the public hospital, but was not sick enough at the time to be admitted, or to qualify for the limited amount of AIDS drugs made available by charitable foundations. 

Despite the start of a nationwide program to provide AIDS drugs free to 100,000 of India's poor, there was little hope for Mohini Bai. The only center providing drugs for all of north India's states -- where AIDS prevalence is believed to be low -- is in New Delhi, which has enough for 200 patients. 

So she spent her savings of $150, or about three months' wages, for the counsel of a local faith healer. 

In this rural area, where literacy rates are a low 38 percent, nurses at the health clinic try consistently to persuade patients to avoid traditional faith healers and untrained practitioners. Paramedics, known locally as Bengali doctors because they claim to have been trained in West Bengal, provide injections of vitamins and drugs to treat common ailments such as diarrhea and malaria. 

Villagers are often partial to the Bengali doctors because of a belief that Western medicine is more powerful when it is injected -- a myth that is particularly dangerous because reuse of disposable needles is a common practice. A 2002 World Health Organization study attributed 156,000 cases of HIV infection a year to reuse of needles in a region stretching from India to Burma. Dr. Asit Mittal, a skin disease specialist who sees AIDS patients at the Tagore public hospital in Udaipur, said his clinic has little access to antiviral drugs, and lacks equipment to measure CD-4s, the infection-fighting white blood cells that are depleted in cases of advanced AIDS. He fears that a hidden epidemic is beginning to surface in Rajasthan. 

"There could be a whole lot more Mohini Bai's,'' he said. 

Mohini Bai's final illness came on suddenly, and her death hit the Iyengars hard. 

"There was quite some introspection and some anguish about the fact that (Action Research & Training for Health) could not make a difference," Kirti Iyengar said, "and that she fell victim to the common pattern of HIV transmission -- from migrant husband to village-resident wife.''


The Role of Prostitution in South Asia’s Epidemic 
Push for safe sex in red-light districts

Sabin Russell, Chronicle Medical Writer
Monday, July 5, 2004

Bombay -- Sakkubai is a crafty old prostitute, with a mischievous smile, a good heart and hidden depths of pain. 

For most of her 50-or-so years, she has sold sex for money on Falkland Road, one of the most notorious red-light districts in Bombay. She has seen life's rough edges since she was shipped here at the age of 14 from a small village in central India.

Nothing prepared her, however, for the onslaught of AIDS. 

Blood tests among commercial sex workers in Bombay have shown more than half of them are infected with HIV, the virus that causes AIDS. In the past five years, Sakkubai has watched 13 of the women who worked in her rickety brick brothel die of the disease. 

So now she gladly works with the Saheli Project, a local AIDS prevention charity, passing out condoms to her sisters in the profession. "Our lives,'' she explained, "are more precious than money.''

For the customers -- typically migrant laborers, cab and rickshaw drivers, truckers and students -- a visit to a Falkland Road brothel can cost $2 to $4, or perhaps $10 for a longer encounter. Women working the streets outside the brothels will turn a trick for $1 or less. 

Despite India's outward image of sexual modesty, the scope of prostitution in India's largest metropolis suggests a more complex picture, and a troubling one for those attempting to prevent an uncontrolled outbreak of AIDS. 

An estimated 4,000 prostitutes work the Falkland Road district alone. In nearby Kamatipura, an even larger flesh-trade bazaar, as many as 20,000 women sell their bodies to willing buyers. Each woman may serve four to six customers per day. 

As such, the red-light districts of India's cities, and those of Bombay in particular, have been engines driving the growth of the epidemic throughout this nation of more than 1 billion. India today is logging nearly 1,000 new AIDS cases per month, and has an estimated 4.6 million HIV infections. 

In 1997, tests found only 1 percent of Bombay prostitutes were infected with HIV. Just five years later, 54 percent of the sample tested positive. 

Identified as an AIDS hot spot, the red-light districts of Bombay have been the focus of a broad spectrum of public and private disease-prevention and social service programs. They distribute condoms, they provide treatment for sexually transmitted diseases, and they try to care for the prostitutes' children -- to feed and educate them and to provide a home when their mothers sicken and die. Many of these children themselves are HIV positive and need the same care.

"The greatest fear is to die and have no one to grieve for you,'' said Sara D'Mello, director of Ashray, a residence for 62 children of HIV-infected Bombay prostitutes. 

Since 1995, the program -- partly paid for by USAID, the foreign aid program of the United States -- has been home for a handful of the most marginalized of Bombay's 16 million residents. 

Ashray took in a 16-year-old girl who had been left to die in a garbage dump. She weighed 44 pounds. 

"We couldn't get help to lift her up and put her in a police car,'' D'Mello recalled. No hospital would admit her. But the Ashray staff cleaned her up, fed her eggs, milk and vegetables, and saw her will to live return. She lived three more years but died in March. 

"At least they die like human beings,'' D'Mello said. 

In the beginning, Ashray housed about 30 children from 150 families. The numbers have doubled since, but the turnover is constant. "Nearly every month, we have a death,'' D'Mello said. 

The word "AIDS" is never used in front of the children at Ashray, which roughly translates to "hope" in Hindi. The place operates much like any school or day care center in the United States. There's a playroom with a game of Snakes & Ladders (similar to the American game Chutes and Ladders) on the floor, kids' artwork on the walls, clay projects under way on a table. 

A trio of sisters played happily in a group, while their mother lay in bed in another room, suffering from an AIDS-related fever. Another quiet 9- year-old clung closely to the director. Her mother had died a few weeks earlier. 

"She's still coping with the loss,'' D'Mello explained. 

An hour's drive away, in Kamatipura, another group of 80 children of prostitutes gathered for a lunch of rice and lentils. It is served up by the Committed Communities Development Trust, the same organization that runs Ashray. In addition to feeding the kids, the program provides a way for social workers to reach their mothers and sign them up for lessons about AIDS, the benefits of condoms, and how to refuse sex with clients who won't use one. 

In a nearby building, 14 emaciated women sit in a circle, one nursing a listless 4-month-old baby. It is a support group for prostitutes sickened with AIDS. They share their lives, their common fears. Before their meal, they sing a prayer in Hindi: "God give us the strength to fight for ourselves; and bless us with your kind mercy.'' 

The program, called Roshni, is designed to show prostitutes infected with HIV how to live "a positive life,'' said Anagha Dev, a Bombay social worker. The program offers food, painting, drawing and dance. 

"They don't want lectures and talk. They have a lot of problems,'' she said. 

Sex is a 24-hour industry in districts such as Falkland Road, where even in midafternoon women stand impassively, like mannequins, outside of row after row of curtained storefronts. Garbage on Falkland Road festers in picked-over piles 4 feet high, and sewage pools in the gutters. The streets are crowded with pedestrians, honking taxis and the ubiquitous black three-wheeled auto- rickshaws, which buzz and jostle like bumblebees through Bombay neighborhoods. 

Yet this is also a community, with hardware stores, food stalls, restaurants and -- right across from a row of brothels -- a small mobile merry-go-round to entertain local children. 

Into this environment, members of the Saheli Project bring free condoms and the ready advice of "peer educators,'' current and former prostitutes who talk up the benefits of safer sex. 

A mobile van ferries teams of social workers and medical personnel from their offices at the J.J. public hospital to Falkland Road, where they dispense information on HIV along with medical checkups and free medication. They rely on a network of cooperative prostitutes. 

"We now provide condoms to each and every customer,'' said Sakkubai. 

In the dreary world of commercial sex in Bombay, however, it is difficult to imagine the pressures facing prostitutes, who work there not out of choice, but for survival in a land of extreme poverty. AIDS is a modern disease that has intruded on an ancient culture of commercial sex, where eroticism is enshrined in some of India's myriad religious traditions. 

Sakkubai came to Falkland Road as a devadasi, or "servant of god,'' a young girl who is turned over to a life of prostitution by her widowed mother. In a practice rooted in ninth century India, devotees of the goddess Yellamma may turn their daughters over to a temple god in gratitude for the child recovering from an illness. "Married" to this god as young teens, these girls are then deemed unsuitable for marriage to a man. Unable to wed a breadwinner, these girls are trained as sexual servants, and are literally sold to brothels in urban areas. 

Although the practice was outlawed in 1947, the powerful tradition among Yellamma worshipers in the south India state of Karnataka, as well as the financial incentives of the commercial sex trade, keep the devadasi system alive. 

As a 14-year-old, Sakkubai thought she was being sent to Bombay from her rural village in Karnataka to train as a nurse. But her "friend" who accompanied her from the railroad station was instead her "agent." She was quickly initiated into her life as a devadasi commercial sex worker. 

Most young girls in her position expect to live their entire lives in thrall to their "landlords," the brothel owners who skim 50 cents of every dollar earned. The prostitutes also share their earnings with "admins," whose role is like that of a pimp -- procuring customers, providing food and shelter, and handling all their finances, including payments to landlords and payoffs to police. 

Today, Sakkubai continues her work on Falkland Road, surrounded by girls half her age. As a mentor, she urges them to insist on condom use with customers. She estimates that 75 percent of the Falkland Road prostitutes now follow that rule -- an educated guess on which the course of an epidemic may turn. 

As for her own customers, when they insist on condom-free sex, Sakkubai's AIDS prevention program is simple. 

"I tell them to go,'' she said.


Spreading the Message of Prevention 
Outreach workers hit the road to keep truckers protected 
Counselors hand out condoms to break chain of infection

Sabin Russell, Chronicle Medical Writer
Tuesday, July 6, 2004

Madras, India -- It's 9 in the evening at R.P. Star's, a truck stop on Highway 45 south of this seacoast city, and the drivers are pulling over their rigs for a bite to eat, a cup of tea and perhaps a little sex for money with the women in the bushes. 

Thirty-five-year-old Thennarasu is waiting for them as well, standing by an outdoor table with a satchel of AIDS prevention pamphlets, a box of condoms and a willingness to chat about trucks, diesel engines or sexually transmitted diseases. 

"Do you think that only drivers are messing around?'' asks one of the truckers, who had stepped out of a tank truck hauling drinking water to Madras. 

Thennarasu is unfazed by the hostility. 

"When they are asking questions,'' he explains enthusiastically, "I am sure they are getting the message.'' 

Within minutes, another trucker and his young apprentice -- a companion known as a "cleaner" that accompanies almost every driver -- are edging toward his table, watching Thennarasu unwrap a condom from its foil packet. 

He flips the latex deftly in his fingers, unrolls it and snaps it like a rubber band, showing off its strength. Then he rolls another one down a brown plastic penis model, demonstrating ease of use and proper technique. 

As Thennarasu chats up the driver, the cleaner surreptitiously palms another foil packet, slipping it into the folds of his blue mundu, a traditional wrap that coils around the hips and hangs like a skirt. It's another small victory in Thennarasu's war against AIDS. 

Six days a week, Thennarasu and fellow outreach workers from the Hope Foundation fan out to truck stops along a 37 -mile stretch of Highway 45, which runs from the coastal port of Madras to the center of Tamil Nadu, India's southernmost state. They are foot soldiers in the country's most ambitious and effective effort to curb the spread of HIV. 

"We are now actually achieving a reduction in HIV transmission,'' said Dr. M. Senthamizhan, chief epidemiologist for the Tamil Nadu state AIDS control office. By focusing their efforts on the trucker-prostitute relationship -- a key factor in the spread of AIDS in Africa -- prevention experts hope to break the chain of HIV transmission where individual risk is highest and where the danger of spreading the disease across geographic regions is most acute. 

Almost 10 percent of truckers tested in Tamil Nadu were HIV-positive in 1997. In 2003, the infection rate was 4 percent. 

Among Tamil Nadu prostitutes, HIV infection rates have fallen to 9 percent, from 30 percent seven years ago. 

Most significantly, the rate of HIV infection among pregnant women in the state -- the standard measure of how widespread the disease has become in the general population -- had fallen by one-third, from 1.1 percent in 2001 to 0.75 percent at latest count. 

Public health officials from India's 34 other states regularly trek to Madras to learn how it's done. The trucker program in Tamil Nadu is vast and constant. Program managers meticulously document each step in the process -- mapping out truck stop sites and documenting each conversation with a trucker or a prostitute and each referral to a medical clinic to test for HIV or sexually transmitted diseases.

"Small interventions do not work,'' said Dr. Charles Bimal, director of the Madras-based AIDS Prevention and Control Project, which runs the trucker program. "It takes a lot of effort. You have to have resources.'' 

The organization relies on a $15.5 million, five-year grant from USAID -- 

the American foreign aid program -- and the national government of India. It costs $400,000 a year to run the trucker intervention programs at 12 major Tamil Nadu sites. 

Key to its success are professional counselors such as Thennarasu and a network of 9,000 "peer educators,'' who are truckers, restaurant owners, shopkeepers and prostitutes enlisted in the effort to educate their own communities about the danger of AIDS. 

Most of the India's 5 million truckers live away from home for one week to three months at a time, hauling goods over the subcontinent's 5,000 miles of national highways. According to a survey by the AIDS Prevention and Control Project, typical truckers have three to five sexual partners each week on the road. Alcohol and drug use are high. Drivers and their cleaners spend a great deal of their time together on the road talking about women and sex, and about 10 percent also have sexual relationships with each other. 

India's secret weapon against AIDS may well be the dedication of people such as Santhosh Kagoo, who chucked his career as an electronics marketer and moved to Madras with his wife and three children to set up an AIDS orphanage. 

A cheerful little 9-year-old named Meena was one of the first children they took in. She was the daughter of an HIV-positive trucker and was placed at the orphanage by her mother, who was too sick to care for her. AIDS first killed her mother, then her younger sister. When she was 11 years old, Meena died of AIDS as well. 

"Her story made me think of taking care of the truckers,'' Kagoo said. "Only by teaching HIV prevention to the truckers can we avoid their children suffering from AIDS.'' 

So Kagoo and the Hope Foundation took on the management of this stretch of Highway 45, where 4,400 trucks by his count pass by daily. He identified 37 "halting points," where the drivers and their cleaners stop for refreshment, and hired experienced outreach workers such as Thennarasu to work at the four busiest sites. 

There's a similar sense of dedication in Villupuram, 40 miles south of Madras, where the trucker intervention program was first honed into a model for other Tamil Nadu sites, and is now being duplicated throughout India. 

In Villupuram, the AIDS prevention project puts equal emphasis on working with prostitutes, providing them with condoms, counseling and medical attention. 

The years of attention have paid off, and the women of Villupuram's highways are now known for their insistence on condom use. 

"We are able to protect ourselves,'' said a young prostitute, "Selvi," during a discussion at a roadside dhaba, a restaurant catering to truckers. Speaking in her native Tamil, she added, "The awareness of AIDS among the common people is not as high, and they are the ones getting sick. For sex workers, the fear is there. We insist on condoms. This is our profession.'' 

At Hindustan Automobiles, an auto parts shop off Highway 45 in Villupuram, store owner Shajahan sells spark plugs, fan belts and oil filters, and throws in condom demonstrations, using the plastic penis, free of charge. 

While truckers and mechanics wait for their parts or for their engines to be repaired in nearby garages, Shajahan also offers AIDS pamphlets and advice about sexually transmitted diseases. He has been doing it for six years. 

"This is a social service," he said. "I want to save my friends and my community." 

Benjamin Franklin, a senior consultant to the Villupuram program, said role models such as Shajahan had been crucial to its success. There has been an added benefit for Villupuram. 

"Peer education," Franklin said, "has created new leaders in this community."


Increased funding fails to curb AIDS 
$5 billion not enough to halt global epidemic

Sabin Russell, Chronicle Medical Writer
Wednesday, July 7, 2004

Despite an increase in global spending to fight it, the AIDS virus continues to spread throughout the developing world, infecting nearly 5 million people a year and exacting a terrible cost in human lives and suffering, global health authorities said Tuesday. 

In advance of a world summit on the epidemic convening in Bangkok on Sunday, new estimates show that 38 million people around the world are infected with HIV, the virus that causes AIDS. Each year, 3 million people die of AIDS, including 500,000 children. 

Since it surfaced in California more than two decades ago, the epidemic has claimed 20 million lives, according to UNAIDS, the Joint United Nations Program on HIV/AIDS. 

"We shouldn't be surprised that HIV continues to spread,'' said Dr. Peter Piot, director of UNAIDS, during a telephone press conference from London. 

Global spending to fight AIDS has increased to $5 billion -- a 15-fold increase from the $300 million spent in 1996, when the first effective treatments were found. Yet this is not nearly enough, according to Piot. 

"We have less than half of the $12 billion needed in 2005 to contain AIDS in developing countries,'' he said. By 2007, UNAIDS predicts $20 billion will be needed for prevention and treatment of the disease. 

While Piot and other global health experts are convinced the epidemic is expanding, the latest estimates demonstrate the weaknesses of the system used to calculate its spread. 

For the second time in the past two years, the Geneva-based agency has had to roll back its estimates of how many people around the globe are infected. 

In November, UNAIDS estimated there were 40 million infections, and in 2002 the estimate was 42 million. 

Each apparent reduction in HIV cases, according to UNAIDS epidemiologist Karen Stanecki, is the product of more refined techniques for estimating the prevalence of the virus. UNAIDS epidemiologists in many cases overestimated the spread of HIV in rural areas of Africa, a fact uncovered only when more accurate house-to-house sampling surveys were completed. 

When disease trackers apply that new lens to the previous estimates, those older numbers shrink as well, but the experts contend that the new picture still shows an expanding global pandemic. Using the new model, UNAIDS estimates that 4.8 million people were infected with HIV last year -- more than ever before, the agency said, while acknowledging that direct year-to- year comparisons are not valid because they are based on different estimation techniques. 

The difficulty of explaining how an apparently shrinking epidemic is, in fact, expanding, is not lost on AIDS experts. 

"It doesn't necessarily serve the cause well to continue to overestimate the numbers,'' said UCLA professor of infectious diseases Tom Coates. "They do run the risk of crying wolf, and then backtracking.'' 

In defense of the UNAIDS statistics, Coates said that making these global estimates had always been a difficult task. "Particularly in rural areas, there just isn't proper surveillance.'' He also noted that, whether 3 million or 5 million are becoming infected with the virus each year, "It is still bad. '' 

The global snapshot of the AIDS epidemic did carry some hints of good news: There are signs that the disease may be stabilizing in sub-Saharan Africa, where two-thirds of all people living with HIV live today. For years, the region has been the site of the most explosive increases in HIV. Infection rates among pregnant women in Swaziland, for example, increased to 39 percent in 2002 from 4 percent in 1992. 

Now, UNAIDS is recognizing that the steep rise in the percentages of those infected in sub-Saharan Africa has flattened. Unfortunately, that trend is partially explained by rising numbers of AIDS deaths.

But the epidemic continues to expand in Eastern Europe. With 3 million intravenous drug users, Russia has been hit hard. Eighty percent of those infected are under the age of 30, compared with 30 percent in North America and Western Europe. Women now account for one-third of new infections in Russia, up from one-quarter in 2002. That is a particularly disturbing sign suggesting that the epidemic is moving out of high-risk groups and into the general population. 

Piot also said that in Asia, the AIDS epidemic tended to be focused in high-risk groups such as prostitutes and their customers, drug users and gay men. 

If prevention efforts there are focused on these groups, he said, "I don't think we will have an African-type scenario.''


CHART (1): 

Newly infected AIDS cases highest yet 

In 2003, an estimated 4.8 million people became newly infected with HIV, the virus that causes AIDS - more than in any previous year. Currently, 37.8 million people are living with HIV. 

Global estimates of HIV and AIDS as of the end of 2003 

North America: 1 million 

Latin America: 1.6 million 

Eastern Europe and Central Asia: 1.3 million 

Oceania: 32,000 

South and Southeast Asia: 6.5 million 

Sub-Saharan Africa: 25 million 

North Africa and Middle East: 480,000 

Western Europe: 580,000 

Caribbean: 430,000 

East Asia: 900,000 

Source: U.N. Program on HIV/AIDS (UNAIDS) Associated Press Graphic


CHART (2): 

18.7 million men living with HIV 

17 million women living with HIV 

2.1 million children under 15 living with HIV 

4.8 million new cases of HIV in 2003 

4.8 million new cases of HIV in 2003 

2.9 million AIDS deaths In 2003 

Source: UNAIDS 


Unanswered Questions 
Epidemic imperils the future 
Nation could face Africa-like disaster

Sabin Russell, Chronicle Medical Writer
Thursday, July 8, 2004

New Delhi -- At his office in the All India Institute of Medical Sciences here, Dr. Pradeep Seth unrolled a large multicolored map of his native country. 

The chief of microbiology at India's most prestigious medical school, Seth traced with his finger the paths of the AIDS epidemic, as it moved east from Bombay, west from Madras, and down from the heroin trade routes in the far northeastern border states of Nagaland and Manipur. 

A brilliant son of parents who fought for India's freedom from British rule half a century ago, Seth was describing the invasion of an alien microbe that threatens the lives of millions of his countrymen. 

In his crowded laboratory down the hall, biologists have also parsed the genetic fingerprints of the various viral strains as they evolved in India, identifying those descended from HIV in southern Africa and those from Southeast Asia. 

Seth's goal is to develop a successful AIDS vaccine tailored to the family of HIV, known as subtype C, that now predominates in India. Using some of the world's most advanced genetic engineering techniques, his laboratory has designed a vaccine that has shown promise in tests on monkeys and may be cleared for human trials next year. 

"If my vaccine succeeds in only 50 percent of cases, it will save 1,000 lives per day,'' he said. "I am a great believer in God's kindness.'' 

Such serenity and optimism in the face of long odds and potential catastrophe is not unusual in India. AIDS is one of many challenges facing this resilient nation that has weathered famine, earthquakes, war and plagues. 

A few miles to the north of the capital city's medical complex, a new national government is settling in as the surprise victors in this spring's 3- week-long election in the world's largest democracy. 

New Delhi, the seat of political power and policy-making in India, is the place where decisions will be made that will determine the future course of the AIDS epidemic in India, and perhaps throughout Asia. 

Estimates are that among India's 1 billion people -- one-sixth of the world's population -- only 0.5 percent are infected with HIV, the virus that causes AIDS. However, that translates into 4.6 million infections, more than any other nation except South Africa, where an estimated 5.3 million adults and children are HIV-positive. 

Yet India spends far less per capita on HIV, about 11 cents, than many impoverished African nations. Uganda, for example, spends $1.81 per capita on AIDS prevention. The United States, by comparison, will spend $63 per person, or $18.5 billion, for its domestic and foreign AIDS programs in 2004. 

India's handling of its AIDS epidemic was not an issue in the election, which restored power to the Congress Party after six years of rule by the Bharatiya Janatha Party (BJP). But if the dire predictions of runaway disease come to pass, AIDS could present the new prime minister, Manmohan Singh, with his gravest crisis. 

"AIDS is one of the principal question marks hanging over India's future, '' said the authors of a January report on the epidemic by the Center for Strategic and International Studies, a Washington think tank. "This is a moment of special opportunity in India, a time when a decisive increase in support for its HIV/AIDS programs can really make a difference,'' said the report, titled India at the Crossroads. 

Colorado College President Richard Celeste, a former U.S. ambassador to India who headed a delegation to India with former U.S. Health and Human Services Secretary Louis Sullivan, had hoped the center's report would nudge the Bush administration to add India to the list of 15 countries eligible for emergency AIDS relief. However, Vietnam was chosen to complete the list. 

"I was disappointed," Celeste said. "I think India is ripe for the kind of collaborative effort the designation would have enabled.'' 

In announcing his choice of Vietnam, President Bush suggested that other countries hadn't shown as much interest. "People have got to say, 'I've got a problem, come and help us,' '' Bush said. 

The question that unnerves world health experts is: Will India become the next Africa, where more than 30 percent of the adults in some nations are infected? 

Despite mounting concern about AIDS in India, the epidemiological picture is not clear. Although HIV is becoming entrenched in high-risk communities, in 18 years it has yet to blister through the general population as it has done repeatedly in African nations. 

In Africa, studies suggest that the explosive rise of HIV rates may be related to cultural practices where both men and women have more than one long- term sexual relationship going on at a given time. These "concurrent" partnerships -- unlike serial monogamy -- overlap for periods of months or years. They create a "sexual network" of participants, all of whom can be quickly infected if one of them picks up the virus. Behavior surveys in India show that women are much less likely than men to have more than one sexual partner. 

"The sexual networks are not there in India to sustain a large-scale, generalized epidemic,'' said epidemiologist Daniel Halperin, senior prevention adviser to the U.S. Agency for International Development, who wrote about concurrent partnerships in the July 3 issue of the Lancet, a British medical journal. 

A U.S. National Institutes of Health-sponsored study of HIV infection rates in 28 slum neighborhoods of Madras, also known now as Chennai, found a surprisingly low prevalence of 0.2 percent among women, and 1 percent among men -- strongly suggesting that the presumed nationwide rate of 0.5 percent is too high. Results of the survey led by Johns Hopkins University epidemiologist David Celentano will be presented next week at the 15th International AIDS Conference in Bangkok. 

"It shows that, in south India, the HIV epidemic is still concentrated in high-risk groups and has not reached the general population,'' Celentano said. 

A recent World Health Organization analysis concluded that "the prevalence of HIV has leveled off in India, and further substantial increases are unlikely to occur.'' 

Nevertheless, leading global health experts are deeply worried, because HIV is now firmly established in at least 50 "hot spots" throughout India. The country does not need a 30 percent infection rate for AIDS to become a vast human tragedy. If rates creep to just 1 percent of India's population, there will be 10 million HIV-positives in a nation with limited health care resources. 

"India has all the ingredients for the epidemic to explode into a major problem,'' said Dr. Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, in Washington, D.C. 

Dr. Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, sees in India today conditions reminiscent of those in Africa 15 years ago, when -- in hindsight -- Western leadership might have helped African nations avert the disastrous spread of AIDS on that continent. "In country after country, they denied, denied and denied the scope of the epidemic," he said. "They did too little, too little, too little, until it was too late.'' 

Another potential vulnerability in India: Aside from the large Muslim minority, most males are uncircumcised, as are men in the regions of Africa hardest hit by HIV. Numerous studies in Africa have found that lack of circumcision more than doubles the risk of HIV infection -- possibly because the virus has a particular affinity for cells that line the foreskin. A recent study of Indian men conducted by Johns Hopkins researchers found that uncircumcised men ran a sevenfold higher risk of HIV infection than their circumcised counterparts. 

"In India, you have roughly 800 million Hindus, and 150 million Muslims," said Feachem. "For a great majority of the population, lack of circumcision is a major risk factor.'' 

Although he credits the former prime minister, Atal Bihari Vajpayee, with an improved record on AIDS in the past two years, he said the Indian government response overall had been "grossly insufficient." The new Congress Party government, he hopes, will pick up where Vajpayee left off, and then increase AIDS prevention and treatment programs. 

"It is not too late,'' Feachem said. "If India were to galvanize now, it would become not another Africa, but another Brazil.'' 

Brazil is considered the leading success story in the developing world's battle against HIV. Brazil offered comprehensive HIV prevention plans from the start of the epidemic and, ignoring the protests of patented AIDS drugmakers, began distributing copied versions to HIV-infected patients in 1996. In Brazil's own analysis, the payoff has been: 90,000 deaths averted; a sevenfold reduction in AIDS hospitalizations; and savings of $2.2 billion. 

On April 1, India took the first, tentative steps to provide AIDS drugs to its ailing poor. At the Lok Nyak hospital in New Delhi, six patients received antiviral drugs, among the first of 100,000 who will eventually receive the medications under the government's program. 

But New Delhi itself has been allotted only enough drugs for 200 patients, and it is the only site in the country serving all the states of northern India. Arun Baroka, project director tor the Delhi State AIDS Control Society, is worried that Lok Nyak will become a magnet for AIDS patients everywhere in the north. 

"People from neighboring states will be flocking to us, and that will be a problem,'' he said. 

Steps such as these, however, signal a major change in India's own response to the epidemic. To those who have witnessed AIDS play out its fearful script in Africa, it is a harbinger of hope. 

"Turning the tide on HIV-AIDS in India,'' said Feachem, Global Fund executive director, "is of critical importance for the whole world.''

 

AIDS Research Chief Altered Safety Report 

 By JOHN SOLOMON, Associated Press Writer 

WASHINGTON - The government's chief AIDS researcher removed some negative safety conclusions from a subordinate's report on a U.S.-funded drug experiment, then ordered the research to resume over objections from his staff, memos show. 

As justification, Dr. Edmund Tramont, chief of the National Institutes of Health AIDS Division, cited his four decades of medical experience and argued that Africans with an AIDS crisis deserved some leniency in meeting U.S. safety standards, according to interviews and documents obtained by The Associated Press. 

Tramont's staff, including his top deputy, had urged more scrutiny of the Uganda research site to ensure it overcame record-keeping problems, violations of federal patient safety safeguards and other issues. These problems had forced a 15-month halt to the research into using a single dose of nevirapine to prevent African babies from getting AIDS from their mothers. 

AP reported Monday that NIH knew about the problems in early 2002 but did not tell the White House before President Bush launched a plan that summer to spread nevirapine throughout Africa. 

Now, officials have new concerns the lone dose of nevirapine may cause long-term resistance to AIDS drugs in the hundreds of thousands of African patients who received it, foreclosing future treatment options. 

In July 2003, Dr. Jonathan Fishbein, an expert NIH hired to improve agency research practices wrote Tramont: "I am not convinced that the (Ugandan) site is indeed prepared to become active." 

Fishbein contended he should be given time to review Uganda's capabilities and safety monitoring before letting the site reopen, or NIH would risk being "toothless" in its new efforts to clean up sloppy research practices. He added that professional safety monitors hired by NIH had reservations about the site. 

Tramont dismissed the safety monitors' concerns, saying he didn't believe they fully understood AIDS.

"I am convinced that this site is ready to resume given the limitations of doing research in any resource-poor, underdeveloped country," Tramont wrote July 8, 2003, in response to Fishbein. 

"I want this restriction lifted ASAP because this site is now the best in Africa run by black Africans and everyone has worked so hard to get it right as evidenced by the fact that their lab is now certified," he wrote. 

NIH officials acknowledge Tramont rewrote the report and overruled his staff on the reopening, but said he did so because he was more experienced and had an "honest difference of opinion" with his safety experts. They noted Tramont had no financial interest in nevirapine and that the troubled study began well before he joined NIH in 2001. 

Those who raised objections "were part of a large team of which Dr. Tramont was the head, and it is important that the people involved in that team should express their opinion and there should be discussion," said Dr. H. Clifford Lane, the NIH's No. 2 infectious disease specialist and one of Tramont's bosses. Lane was designated by NIH to speak to AP on Tramont's behalf. 

"But at the end of the day, the final responsibility lies with the head of the team, and it is his job to put that together the way he sees it," Lane said. 

Lane said an internal NIH review concluded Tramont had not engaged in scientific misconduct. Separately, the National Academy of Sciences continues to investigate whether the Uganda research was valid. 

NIH believes it helped save hundreds of thousands of African babies by allowing nevirapine to be used in single doses to block the AIDS virus, Lane said. But he acknowledged the research was imperfect, and NIH now believes nevirapine should no longer be a first choice for newborn protection — if other options exist — because of the newly discovered problems with resistance. 

One of the nation's premier AIDS charities said Tuesday it is concerned the controversy over the 2002 study problems will cause African countries to stop using the drug, and called on medical experts to find ways to get better new solutions into the Third World. 

"Rather than focus on withdrawing nevirapine from those who urgently need it, the entire world should focus on how we can provide the funding for infrastructure improvements, training, and drug purchase costs so that more and more women will have access to the most effective drug regimens possible," the Elizabeth Glaser Pediatric AIDS Foundations said in response to AP's stories. 

Tramont wrote in 2003 e-mails that he reopened the clinics because he didn't want NIH "perceived as bureaucratic but rather thoughtful and reasonable" and that it was important to encourage Africans' fight against AIDS "especially when the president is about to visit them." 

Bush visited the continent a few days after Tramont ordered the clinics reopened. 

Tramont's actions, however, drew criticism from his top deputy. 

"I think we are cutting off our noses to spite our face here," AIDS Division Deputy Director Jonathan Kagan wrote. "... We should not be motivated by political gains and it's dangerous for you, of all people, to be diminishing the value of our monitors." Tramont prevailed. 

Five months earlier, Tramont surprised one of his own medical officers, who had written a report summarizing safety concerns uncovered during a second review of the Uganda trial. 

Dr. Betsy Smith's report, finished in January 2003, said the Uganda trial suffered from "incomplete or inadequate safety reporting" and records on patients were "of poor quality and below expected standards of clinical research." 

She strongly urged NIH not to make sweeping conclusions about nevirapine based on the Uganda research. "Safety conclusions from this trial should be very conservative," she wrote. 

Behind the scenes, Tramont asked to see Smith's report before it was submitted to medical authorities, including the Food and Drug Administration "I need to see the primary data — too much riding on this report," Tramont wrote Jan. 23, 2003. 

A few weeks later, the safety report was published and sent to FDA without Smith's concerns and with a new conclusion. 

The study "has demonstrated the safety of single dose nevirapine for the prevention of maternal to child transmission," Tramont's version concluded. "Although discrepancies were found in the database and some unreported AEs (adverse reactions) were discovered ... these were not clinically important in determining the safety profile." 

In disbelief, Tramont's staff began inquiring how Smith's report got changed. An answer came back from the top. 

"I wrote it," Tramont responded.