Dr. Chris Beyrer, Director of the Johns Hopkins Fogarty AIDS International Training and Research Program, talked with AsiaSource about the issues surrounding the rapid spread of AIDS in Asia. The Fogarty program offers training, fellowships and research for developing country scientists who are dealing with HIV/AIDS in their countries. It focuses primarily on India, Thailand, China, and a new collaborative program between Thailand, Malaysia and Laos. Dr. Beyrer works mainly on HIV prevention research, trials of prevention strategies, and the efforts to develop an HIV vaccine. With a specific focus on AIDS in Burma and Cambodia, he has published several articles on political, social, and medical problems surrounding the spread of HIV in Asia. At the 5th international AIDS Congress in Malaysia (Oct.23-27, 1999) he presented two talks titled "Overland heroin trafficking routes and HIV spread in south and southeast asia" and "Shan women and girls and the sex industry in southeast Asia; political causes and health and human rights implications."
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• What have you observed as general trends in the spread of AIDS in Asia?
• What populations are most effected?
• What are the latest treatments? Are they reaching Asia?
• How has AIDS effected women and children in Asia?
• How has AIDS effected activism in Asia?
• What stage do you see efforts in developing an AIDS vaccine for developing countries?
• How have culture and religion played a role in the battle against AIDS in Asia?
• What do you think are ways to battle the spread of AIDS in Burma given the Burmese junta's complicity in the drug trade?
• How has AIDS become a human rights issue in Asia?
• How have Asian governments and NGOs been responding to the spread of AIDS? Is their regional cooperation?
• What are the goals of the upcoming 5th international AIDS Congress in Malaysia? What issues are they addressing?

What have you observed as general trends in the spread of AIDS in Asia? In which countries have the cases been rising?

It might be useful to frame it to some extent by the perspective of decades. During the first decade of AIDS, about half of it is from 1980 to 1985, nobody knew what was happening. HIV tests were licensed in 1985. So the virus was spreading for a considerable amount of time and with considerable speed in much of the world before we knew anything about it. At that time when we finally had a test to look for the HIV virus, it was very clear that what we saw basically was sub-populations in the United States and Western Europe which would be gay men, drug users, hemophiliacs and heterosexuals in Africa. That really was the principle picture. In the next decade, unfortunately, despite a lot of effort on behalf of an awful lot of people, what we've seen is a worsening and, in some cases, an acceleration of the epidemic in Africa.

Then there is unfortunately this rapid spread of HIV in Asia which began fairly consistently sometime around the late 80s. Thailand, for example, had very little HIV despite a lot of risk behavior in 1987 and 1988 and really had its explosive takeoff in 1989.

Most of the cases in China were scattered, sporadic, and very unusual until about the early 1990s when there was an outbreak in Yunnan on the border with Burma. Then after 1996 for the first time it spread outside of Yunnan among drug users. Now it's a very rapidly rising epidemic.

Probably nowhere has the epidemic spread more quickly and more explosively than in India, which is to some extent a function of how dense that population is and how many people there are with lack of education. It is also a function of what is going on with their medical system because they have not succeeded in cleaning up the blood supply. This is, I think, a very important point that people often neglect. Once we had the test in most developed countries, there was a very rapid drop in HIV associated with blood products: hemophilia, surgery. But in poor parts of the world, this has continued to be a problem. In India, at least about two or three years ago, it was still the case that a third of the infections are thought to be associated with blood transfusions. This is because there are so many private blood banks, unregulated blood banks, inadequate testing, and of course other kinds of spread through unsterile equipment and unsterile procedures. There is also people's preference for injectable drugs--a lot of them are completely useless. People love getting bags of Dextrose where they could just as easily get the same value out of drinking a Coca Cola. But there is a demand to be hooked up to an IV and then you get not only HIV but Hepatitis B, Hepatitis C, tetanus, syphilis, malaria. It's not pretty. But it's very common. This certainly is also a factor in some of the other really resource poor countries like Cambodia.

What populations are most effected? Reports usually point to drug users, sex workers, and migrants as high-risk populations.

The focus has often been on high-risk groups. That is an unfortunate outcome of the way the epidemic looked in the west. For example, in central southern Africa – who is at high risk? Young women of childbearing age and all heterosexual men, and we put those two pools together and you have a tremendous percentage of the population. Are they high risk? Yes! They don't have to be sex workers or to have had a blood transfusion. That is a function of the fact that once this virus gets out of high risk population, and begins to spread in general populations, the risk for everybody who is sexually active goes up in a heterosexual epidemic.

At this point, for example, China does not have much evidence of heterosexual spread; and we really are talking about drug users overwhelmingly. But there are a number of countries that have moved beyond this, and India certainly would be one where the rate in married, monogamous women has reached the level that you see in sex workers. This was just published last year by my colleagues here. There are tremendous rates of HIV in monogamous married heterosexual women whose risks are the fact that they're married and that their husbands are engaging in risk behavior that they have no say in, which, unfortunately, is the Asian model in general. Women across Asia, particularly in the lower end of the socio-economic strata have very little power or negotiating ability over their husband's sexual behaviors. These are cultures, whether or not they approve or sanction prostitution at a cultural level, in which it is ubiquitous and widely used, cheap and unhealthy.

That is the case all over India. It's certainly the case in Bangladesh, Burma, Cambodia, Thailand, Vietnam, and China. So male sexual behavior has really driven this epidemic in Asia in a big way. The other countries that have now reached the point where general population heterosexual spread is a significant or even majority of cases would be Burma, Cambodia, increasingly Vietnam and certainly India. This is also happening in Papua New Guinea which has the worst epidemic among the Pacific countries.

What are the latest treatments? Are they reaching Asia?

Unfortunately we have this paradox, and it's a very painful paradox, and that is in general that the countries that can afford these drugs are not the countries that have significant epidemics. So for example if you were a person with AIDS and good health insurance in Taiwan you probably would get a fair and reasonable access to treatments. The same would probably be true in Hong Kong, Japan and probably in South Korea. These are not countries that have significant epidemics.

The places where the largest number of people with HIV infection anywhere in the world are in India, and the overwhelming majority of those people, somewhere now in the range of 6-8 million people, don't know they have HIV and have not been tested. The consequences of testing are not without problems, particularly if HIV status is revealed. Almost none of these people are getting any access to treatment.

Certainly in Burma there is absolutely no treatment, and there isn't going to be. Cambodia, also, cannot afford this. Cambodia and Burma are the only two countries where the population prevalence, in other words the rate in the population, is approaching African levels where you would have as many as say 1 in 25 or even 1 in 20 adults with HIV infection. Those are the two highest rates in the region. They, of course, are two of the poorest countries in the region.

Now, there has been more effort to try and get antiviral drugs out there is in the case of perinatal transmission. We do know that in the case of a short course of AZT, one drug alone, can have a huge impact on preventing infection. Thailand and Malaysia have really tried to implement AZT for pregnant women. Of course, that is a very short course, and it's a very different thing than trying to implement antiviral therapy for a large population.

One drug treatment like AZT alone is no longer standard for AIDS care. This method isn't used because the virus gets resistant to one drug, so combination drugs are now used. The new class of agents, which we call HART, (highly active antiretroviral therapy) includes the protease inhibitors, the nucleoside analogs, and the non-nucleoside reverse transcriptase inhibitors. Basically you need multiple drugs, at least three. The majority of the people on the best care are on more like four or five from different classes of antiviral drugs. Plus drugs to treat the other opportunistic infections or prevent opportunistic infections.

How has AIDS effected women and children in Asia?

It's abundantly clear particularly in the Asian context that there is going to have to be empowerment of women to respond to this epidemic. That is one of the places where Africa, sadly, has really stumbled and been unable to move ahead. If women don't have some sexual power, negotiating power and can't protect themselves, and we can't get some new technologies that are under female control such as the condom (strictly the male condom anyway is so much under male control) then we're really going to have a problem dealing with these heterosexual epidemics. Our research is trying to come up with vaginal products that women can use with or without male consent that would be under their control that would give them some protection.

It extends, of course, to children. We have a huge number of orphans, more than 80,000 now. Even if they are HIV negative, which the majority of children born to infected mothers are negative (more than two-thirds even without treatment) and are going to survive, they still get the same kinds of stigma. They can't go to school, nobody wants to eat with them, they are socially ostracized, and face discrimination in marriage. You know the likelihood is that this kind of denial of opportunity and possibility is actually going to make [these children] vulnerable to HIV when they become of age.

How has AIDS effected activism in Asia?

One of the things that's been very heartening is that HIV/AIDS activism, because it's regional and international and because there's been this kind of support from UNAIDS and other agencies, has really jump started activism of some other kinds. So, for example, a number of countries where there hasn't been much of a gay movement, AIDS activism has really helped get a gay movement going. The same thing has happened with sex workers. The first real attempt for sex workers in India to unionize has come out of a response to HIV.

What stage do you see efforts in developing an AIDS vaccine for developing countries? A World Bank report said that most research has been on the sub-type B virus that is the predominant sub-type in North America and Europe, but there has been little testing on sub-types prevalent in developing countries. Is this still the case?

Well, this is a rapidly changing field. I would say that that is true. There is no question that in general that is unfortunately the case. Where it's most painfully the case is in Africa where you have multiple subtypes and a number of unique subtypes; and where, I think it's fair to say, that there is almost no research that as far as we know would work against all these African subtypes. Perhaps more than anywhere else along with Asia. All things being equal, in about by 2010 Asia will have outstripped Africa in terms of HIV; and that's because the epidemic is very rapid, but also because the AIDS populations are so huge. I mean India itself is larger than the whole of Africa. That's an epidemic totally out of control.

But the exception in terms of HIV vaccines to this rule is Thailand. Early on in 1993, Thailand was the first developing country to approve a national plan for HIV vaccine development and began working with pharmaceutical companies. Our research group and other groups provided isolates from newly infected Thai subjects and patients in our trials and hospitals such that the manufacturers had access to the Thai viruses. So now there are at least three HIV vaccine candidates, probably four, that have been developed that fit the picture of the subtypes in Thailand. There are two viruses: subtype B and subtype E which is the predominant one. Right now the first clinical trial to test an HIV vaccine for efficacy in the world has started, and that is a joint U.S./Thai collaborative trial. In the U.S. trials are being done among gay and bi-sexual men. In Thailand it's being done among IV drug users.

There is a very important lesson for developing countries here which is they are going to have to follow the Thai model and engage. Engage international researchers, engage the pharmaceutical industry, make it clear that they're willing to be partners in vaccine research. Unfortunately there are always these issues with first-world/third-world research about the use of human subjects and anxieties that governments have about drugs being tested in their country that will subsequently be unaffordable in their country.

If a country chooses to follow the Thai lead and engage, then the pharmaceutical industry is willing to invest. If they feel that all they're getting is heat for not developing a vaccine for countries that aren't interested in working with them it's not going to get us anywhere. India has been somewhat resistant but is really beginning to come around. It's very heartening because there's been a kind of political paralysis in India in terms of dealing with HIV that hopefully is really turning.

China is very actively taking a lead in HIV vaccines. They want to do their own vaccine development, are eager to collaborate with foreigners and scientists, and are also investing in Chinese science, people, and infrastructure to move this forward. So I'm actually very optimistic that Asia is going to play a huge role in this.

How have culture and religion played a role in the battle against AIDS in Asia?

These barriers have been so strong. It's been so painful. I've been involved in this for a number of years. It's as though each and every country is unable to learn the lessons for their neighbors or from the west and has to go through this whole process all over again starting out with a very recognizable phase of denial. The Indian Minister of Health stood up in 1995 and said India will be protected by Indian family values, to which one wants to point out– Which Indian family values? Like husbands and wives can't talk about sex. Like husbands go to prostitutes when their wives are pregnant. Like wives get STDs and come in with discharges, and their doctors don't tell them that they have gonorrhea. They don't want to embarrass the husband. Those family values? Unfortunately, you know, this has had catastrophic effects.

In Burma, which is a country I'm very involved with, the Minister of Health just reiterated that there are no more than 12,000 or 13,000 infections and that there is no prostitution in Burma because it's illegal, and the problem of drug users has been overstated. Well the UN which uses very conservative estimates that were developed in collaboration with the Ministry of Health in Burma and that I helped analyze, estimated that there were 440,000. That was in 1995, and we think it's doubled. Just to give you an idea of how off this can be. Then when a country finally does start to respond, and usually it's not because of science or political pressure, it's usually because people start dying and hospitals get full of AIDS patients and people begin to realize that this is not just an obsession of those westerners.

You wrote in your article in the Lancet, "the easy availability of heroin in Burma has led to its growing use inside the country, especially intravenous use of the drug, and is contributing to a dramatic increase in HIV infection throughout the region." What do you think are ways to battle the spread of AIDS in Burma given the Burmese junta's complicity in the drug trade?

I think from a regional perspective, states are going to have to put pressure on the Junta. I mean the U.S. has already put all the pressure we have. We have sanctions, we have a visa ban, we cut off IMF loans. Every tool this Administration has been aimed, but [the junta] still are supported, and their military budget is supported by China. If the Chinese are serious about dealing with this heroin problem, they're going to have to put pressure on them. Burma is their client state at this point. Burma's epidemic and the heroin problems in Burma really are responsible for the worst epidemic in China which is in Yunnan on the border with Burma.

This perhaps opens a broader question which is what are the things that have worked in terms of HIV prevention? You have to have a functioning public health system. Thailand's tremendous response and really declining HIV rates have so much been a function of the efficacy of that public health system. People getting out there, getting into brothels, doing education in schools, getting condoms out there, reducing STDs; and I think Burma is an example of a health system that has been gutted to support a military budget and that is really incapable of responding to anything--HIV included. Cambodia is slowing, painfully, step-by-step in the process of attempting to rebuild what was a completely destroyed public health system. So again, a poor prognosis.

Another necessity is access to information. In military states where information is limited by law, including Burma, Laos and Vietnam, there is heavy censorship. It's harder to get prevention messages across. But one thing that we think is really having an impact in Burma is radio because it's the only media that gets in there uncensored. Radio is very effective and it's cheap. It's widely listened to, and so we've been developing, with funding from the State Department, a 25 part series on HIV/AIDS in Burmese that was aired on Radio-Free Asia. We have a regular program with Voice of America and with BBC and some of the other radio programs. So that is, in fact, one of the reasons why the Junta admitted that there was HIV in the country at all. After we bombarded them. We know that they all listen to it too.

How has AIDS become a human rights issue in Asia?

I think the prison situation definitely involves fundamental denials of human rights. One of the early studies done in drug users on Thailand found consistently, and we're still seeing this in our studies, that incarceration is associated with HIV infection. It's a major risk for infection. You know there are several reasons why that would be the case. Certainly one is that drugs are available in many countries. Prisons, needles, and syringes are extremely rare and hard to get. So prison is a bad place in terms of drug exposure. Secondly, prison hospitals are almost uniformly across Asia horrendous places where you do not want to be sick in. So there may be AIDS spreading there.

Third, is that at least among male prisoners, there's a lot of sex in prison; and it's totally denied in most of these countries. Even Thailand which has no law against homosexuality doesn't allow distribution of condoms in prison. The United States is just as bad. We have 48 prisons, state and federal prisons, in New York State and four of them allow condoms. This is a major issue in Asia, and it's a major unresolved issue. The head of India's prison system resigned over the demand from the UN that India supply condoms in prison. Her argument was that homosexuality is a western problem and denied the existence in Indian prisons. If you talk to anyone who has been in an Indian prison, that's not the case.

But for the majority population, who is not incarcerated, [human rights] also is a fundamental issue. Very few countries in the developing world have adequate protection on confidentiality. The right to know is a major problem, and there are still many places where counseling is inadequate and people do not really have the right to know. Family members get told first. Husbands get told, not wives, and that's a big problem. Discrimination and social stigma is probably the single most important human rights issue. It's absolutely vast, and it has really created an incredible amount of suffering throughout the region.

So it's a huge problem for Asia, and it's very under addressed. There is discrimination in work. For those countries that actually are at the level where they have insurance, there is discrimination of insurance. There are also human rights issues with travel that are very important. The U.S. remains one of the countries that have this ridiculous visa ban. That's why we never have the International AIDS Meeting in the U.S. They're not allowed to come here. Yes, George Bush signed that into law.

How have Asian governments and NGOs been responding to the spread of AIDS? Is their regional cooperation?

I think there's a lot of regional efforts in AIDS that are really going to be important. Certainly the Thais, again, have been very active in this in terms of Thai Ministry of Health involved in Vietnam, involved in Laos, involved in Cambodia; and more of that kind of work is going to have to happen. The local and regional NGO activity around this epidemic in Asia and the connections between NGOs is extraordinary. A good one, for example, is the Asian Harm Reduction Network which is a kind of umbrella organization of NGOs that works with harm reduction for IDUs. It is stated with Australian money, but it is based in Northern Thailand; and it involves people from India, Nepal, Thailand, Cambodia, Vietnam, China. They do workshops, training, outreach and policy that are really trying to push governments to move forward on policy. I think UNAIDS has played a tremendous role in the region in supporting NGOs and then helping them get linked up together. Southeast Asia AIDS Network allows NGO people even in very remote places, as long as they get on E-mail, to get updates, to communicate, to ask for things like "anybody have a workshop training on gynecological manifestations of AIDS?" Then you see this information. So those networks have been very important.

What are the goals of the upcoming 5th international AIDS Congress in Malaysia? What issues are they addressing?

In the context of the Malaysia meeting that's coming up, this is the first one of these that has been put on by an NGO. You're going to see a strong NGO presence and lots of community activists and HIV/AIDS activists.

The title of the conference is "The Next Millennium: Taking Stock and Moving Forward." "Taking stock" to me means looking, for example, at what prevention we have, what prevention technologies, what tools we have, and what we can do with them. The fact of the matter is that without anymore research, there's good evidence from several countries: Australia, the Netherlands, the U.K., now Thailand, also Uganda, that you can really have a huge impact on this epidemic if you thoroughly and completely commit resources and time and people to existing prevention technologies. And that has not happened. So I think that's very important. The reasons why it hasn't happened, which are largely political and social and cultural, really need to be addressed.

"Moving forward," hopefully is going to be about the next steps that we need to take. The HIV vaccine is certainly one of them; but, for example, what I would argue, it's probably an unpopular position, is that what we need to do to move forward is clean up India's blood supply for example. And resolve the political deadlock in Burma. So I think there are some very important steps that need to be taken that probably haven't been taken.

Every year you get new countries coming onboard and beginning to respond. So, for example, Indian attendance at the third conference was very minimal. There were almost no people from Nepal. The only Asian donors who were putting any money into this really were the Japanese. The rest of it tended to be foreign donors. Now what you're seeing, at the last one in the Philippines two years ago, is a tremendous number of Indian scientists, Bangladeshis, Pakistanis, Nepalis, and people from Laos. There is really evidence of a widening of response.

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Interview conducted by Cindy Yoon of AsiaSource