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BANGKOK INTL AIDS CONFERENCE: Daily Highlights
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Thursday 7am July 17
STORIES BELOW
--Fighting India's Apathy
--Asia's Migrants Carry HIV Along Transit Routes
--Family care and support for people with AIDS
-- HIV molecular evolution and its implications for the spread of HIV
--Focus on funding at global AIDS conference: US administration's global AIDS policy, whose centrepiece is the US $15 billion President's Emergency Plan for AIDS Relief (PEPFAR)
--Prostitutes protest AIDS-drug test, tenofovir for preventing HIV infection: Bay Area company hit with charges of exploitation
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Fighting India's Aids apathy
BBC News - Wed, 14 July, 2004
Sanjoy Majumder, BBC News,in Bombay
India is looking at ways to contain the spread of the Aids epidemic - but many of its citizens don't want to talk about the issue.
The world's second most populous country has one of the highest infection rates - and more than five million HIV/Aids cases.
To counteract the spread of the virus, the government recently launched its biggest anti-Aids initiative to date.
But efforts are hampered by the fact that most Indians still find sex and Aids taboo subjects.
Stigma
In a corner of the St Katherine's Home in Bombay (Mumbai) a group of children are enjoying their playtime.
But despite their singing and laughter these are not typical five-year-olds - all of them are HIV positive.
They were infected by their parents before they were born and were brought here sick and, in some cases, close to death.
In a society where families are the main source of support, they are looked after by nurses and nuns.
Sister Shanti has 30 children in her care at this orphanage.
She says the hardest part for her is when people turn their back on children as young as these.
"It disturbs me when people discriminate against them.
"They have this disease through no fault of their own. They too have a right to live," she says.
Ignorance
For years many in India ignored the growing threat of Aids. Many simply could not imagine it was something that could affect them.
Down a crowded street in the heart of Bombay is the Unison clinic, one of the few in the city that deals with HIV patients. Ram Kewar is on one of his regular visits - he is among 20 HIV-infected people who come here every day.
He was infected by the virus a few years ago and since then has passed it on to members of his family.
He says he had never even heard of the disease, far less about how it can be transmitted.
"I thought it was just my fate to have got it. It was only much later that I found out why it had happened to me."
The new Indian government has identified Aids as one of its priorities.
But the biggest problem is combating ignorance - and that includes people who are very influential.
"One always hears about Aids and how it's this big problem. But I have personally never come across anyone with Aids or seen anyone dying of the disease," he says.
"I think it's just hype."
Taboo topic
But it's a problem which is not just confined to the poor or uneducated, or even the conservative.
It spreads across Indian society. In a trendy Bombay cafe young men and women draw on cigarettes and sip long cocktails.
They are part of cosmopolitan Bombay's elite - upwardly mobile, liberal and well-informed.
This is one section of Indians who are more open to talking about Aids - but they would never think of doing so at home.
"It has to do with sex and that's something which is an absolute taboo," says twenty-something Rocky Bhatia.
"Most families simply will not bring it up."
Sign of hope
But there's hope at the other end of the social divide.
Falkland Road right in the heart of the city is Bombay's red light district.
For years activists have worked closely with the sex workers operating out of tiny rooms and filthy alleyways off this busy street.
It's a move that is now paying dividends.
Monica is a sex-worker who has seen many of her colleagues die.
In the past decade, Aids has claimed the lives of thousands of sex workers. Now they are learning to be more careful.
Volunteers regularly visit every brothel handing out boxes of condoms and carrying out regular medical tests.
"If a customer refuses to use a condom we return his money and turn him away," says Monica.
"It doesn't matter how much money he offers us. Our lives are more important."
It is a small sign of success for a problem that needs to be tackled on a much larger scale.
Otherwise, it is estimated that in the next 10 years India could have more Aids cases than all of Africa.
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Asia's Migrants Carry HIV Along Transit Routes
BANGKOK (AP, July 14, 2004) - Migrant workers in Asia remain highly likely to contract HIV and spread it along the continent's main routes, and they need better access to health care while in the unfamiliar surroundings of their jobs away from home, U.N. and aid agency officials said Wednesday.
"Mobility exacerbates vulnerability to infection, and it also exacerbates vulnerability to the impacts of the disease once you're infected," said Michelle Munro, a spokeswoman for the Brussels-based humanitarian agency CARE International, citing two new studies.
She said migrant workers interviewed for the study, especially prostitutes, told researchers they were unable to find health care or felt too intimidated to seek treatment because of the stigma surrounding AIDS in Cambodia, Laos, Vietnam and Thailand.
"These health systems are already stretched," she said. "You've got a disease that people are frightened of...so you're at the edges of health care provision. So you don't go to the hospital, you don't go to the clinic because you're afraid someone's going to be rude to you."
Workers who found support got it from local communities and aid organizations rather than official health care programs, Munro said.
Male workers from Thailand and Cambodia who travel for work are increasingly returning home with HIV - often contracted from prostitutes - and infecting their wives, she said, adding that the epidemic also spread in a clear pattern along major roads in India and Pakistan.
Road improvements have prompted a surge in traffic, leading to a greater prevalence of HIV along routes in China, Thailand, Laos, East Timor, Vietnam and Myanmar, also known as Burma, said Lee-Nah Hsu, Southeast Asia representative for the U.N. Regional Task Force on Mobility and HIV .
Companies that build highways should be held responsible for bringing AIDS education programs to rural communities along their routes - who have perhaps had little prior contact with the outside world.
"You need to start when the roads are being built," she said.
Fishermen, sailors, agricultural and construction workers face a particularly high risk of infection and move from country to country, the two reports found.
Government efforts have proved inadequate in fighting the disease among the affected groups and must be improved, she said.
Promboon Panitchkpakdi, a representative for CARE's Thailand operation, said Thai fishermen - most of them young males - showed a particularly high rate of infection because they often visit sex workers onshore after working for stints of one to several weeks at sea.
Workers in Thailand's border towns, often a haven for sex workers due to lax law enforcement, also have shown a high incidence of the disease, he said.
Some 25 million of the 38 million infected with HIV worldwide are in sub-Saharan Africa, but the virus is taking root increasingly in Asia, where 7.6 million are infected.
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IAC 2004: Family care and support for people with AIDS
HDN Key Correspondents Team
At the Global Village of the XV International AIDS Conference, participants from Thailand, the Philippines and India came together to talk about family care and support for people living with HIV/AIDS.
A wealth of experience was shared by participants from Thailand, a country hard hit by the epidemic where the first cases were reported in the early 1990s. Back then, people were dying of an illness denied by the community and by the government. Families were left on their own to find answers to the illnesses hitting family members.
A Thai participant told how families did not have time to grieve in those early days, as neighbours become ill one after the other. There was so much discrimination and stigma that infected people had no access to care from the community or health system. In response, families came together to help one another.
India has had similar experiences. In many cases, HIV positive people have been driven from their homes and left to care for each other.
Prevention was begun relatively early in the Philippines, so cases of HIV and AIDS remained relatively low, as reflected in the national registry of the Health Ministry. Families were prepared early for taking care of sick family members.
In the Philippines, within a decade of the epidemic families have learned how to deal with HIV/AIDS and treat it like any other illnesses. They in fact call it "normalising the problem", which has meant a lot of learning by doing.
No country has been spared the stigma and discrimination that are always attached to HIV and AIDS. Many were the challenges shared by the participants during the session. Volunteers from communities were there, but most of them were not totally prepared to handle caring for a sick person, especially within a home setting.
Surprisingly, the participants to the discussion were all "youth". They all voiced the need to involve people of their age, as many of those who are infected are young.
Participants all agreed that youth, as the age group most affected or infected by HIV, have the right to be engaged in tackling the epidemic. For them, dealing with it at a later time means excluding them from the response.
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IAC 2004: HIV molecular evolution and its implications for the spread of HIV
HDN Key Correspondents Team
The evolution of HIV has been a key factor in the epidemiology of HIV/AIDS. Viral recombination has been demonstrated as a mechanism of HIV molecular evolution for some time now. The Oral Paper Session on Viral Diversity (A02) presented some recent developments in the study of HIV evolution.
Data on viral evolution in five regions of the world -- Thailand, Kenya, Cuba, the Russian Federation and Africa -- were presented. A common theme ran through the six papers of this session; viral evolution is facilitated by human migration, bringing together different HIV-1 subtypes. Genetic recombination between these subtypes generates new strains with greater fitness to survive.
Two papers on viral diversity in Thailand, demonstrated by analysing the gag and env coding sequences of the genome, showed migration of virus from neighbouring countries (Myanmar, Cambodia and Vietnam), which resulted in new recombinant strains (AE/B and AE/C). Sometimes these novel strains were the result of complex recombination events.
While the predominant subtype in Thailand was originally B, an AE subtype (CRF01 AE) has been introduced from neighbouring regions and is now the predominant subtype. From this, AE/B and AE/C strains have evolved.
Clearly, evolutionary advantage, in terms of increased fitness and survival, is what is driving these events.
In Kenya, a mother was dually infected with subtypes A and D in 1996. By 2002, these had recombined to produce a hybrid strain, with a subtype A pol gene and a subtype D env gene.
In Cuba, where many subtypes co-exist, a number of circulating recombinant forms have evolved.
The former Soviet Union has been a centre of subtypes A and B migration, resulting in A/B strains evolving. Some of these show secondary resistance mutations and there are implications for ARV therapy. Again this evolution is driven by epidemiological and biological advantage.
In an excellent presentation, Eric Arts demonstrated the relative fitness of strains of Types M and O of HIV-1 and HIV-2 of African origin. Type M HIV-1 strains were able to compete successfully with HIV-2 strains, which in turn competed much more successfully with Type O HIV-1 strains. Among the Type M HIV-1 strains, subtype C strains were the least competitive, but these still outcompeted HIV-2 and Type O HIV-1 strains.
It is interesting, that being the least competitive subtype of Type M strains, subtype C is a predominant subtype. Competitiveness is assumed to be associated with replicative capacity and viral fitness. Being the least fit of the Type M strains, subtype C may survive longer in people and therefore have a greater chance of being transmitted.
Viral evolution is likely to be driven by two factors: human migration, bringing different strains together, and HIV treatments (ARV and eventually vaccines). We can expect to see a similar, but perhaps more dramatic, effect to that of the evolution of bacterial antibiotic resistance over the last 50 years.
This session was a salient reminder that the struggle to control AIDS will be an ongoing one where we have to aim to stay at least one step ahead of the virus with our treatment and prevention strategies. The issue of HIV evolution is likely to be greater than bacterial resistance, because of the increased mobility of people and also the greater capacity of viruses to evolve compared to bacteria. We should keep in mind the models of bacterial evolution when planning our ARV strategies.
Focus on funding at global AIDS conference
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BANGKOK, 14 July (PLUSNEWS) - United States government officials in general, and Ambassador Randal Tobias in particular, have acted as a magnet for placard-waving activists this week at the 15th International AIDS Conference in Bangkok, Thailand.
Tobias heads the US administration's global AIDS policy, whose centrepiece is the US $15 billion President's Emergency Plan for AIDS Relief (PEPFAR), which aims to treat two million HIV-positive people and prevent seven million new infections over a five-year period, mainly in the 15 worst-affected countries. The US government allocated $2.4 billion in 2004 towards those laudable goals.
But critics argue that the bilateral initiative diverts urgently needed financing away from the Global Fund to Fight AIDS Tuberculosis and Malaria, and accuse President George Bush of acting in the interests of the pharmaceutical industry.
PEPFAR has also been condemned for allegedly pushing an ideological message of abstinence - when that is not an option for many women - and for spending too much on US service providers at the expense of local expertise and capacity.
Speaking at the conference on Wednesday, Tobias said it was time to end divisions in the struggle against the epidemic, as "we are all striving towards the same goal - a world free of AIDS".
His address, however, was delayed by 15 minutes as activists marched to the foot of the podium with placards that read "He's lying".
Tobias' message was that the United States was providing leadership with the single agenda of tackling the epidemic. On antiretrovirals (ARVs), Tobias said he would look at buying cheaper generic copies of brand-name drugs if they were approved by the US Food and Drug Administration (FDA) as there was a "moral imperative" that the ARVs distributed were "safe and effective".
The US government has rejected pre-qualification of drugs by the World Health Organisation, but has promised an accelerated FDA certification process, an offer which no generic manufacturer has as yet accepted.
"It's a hoax - a decoy strategy," charged Dr Paul Zeitz of the Global AIDS Alliance. "Any generic company would be crazy to submit to FDA approval in this environment of a relentless, multiprong strategy to block access to generic drugs."
PEPFAR, launched in 2003, has been a significant new addition to a growing list of international funders, which includes the World Bank's Multi-Country AIDS Programme, the Clinton Foundation, private corporations and the two-year-old Global Fund, set up as a partnership between governments, the private sector and civil society.
As the number of funding sources has grown, so has recognition of the need for harmonisation and streamlining of donor procedures to enable better utilisation of grants.
The so-called 'three ones' - one national AIDS action plan, one national coordinating strategy, one monitoring system - are key to preventing duplication and identifying bottlenecks to aid flows, according to UNAIDS.
Much of the AIDS activists' criticism of the Geneva-based Fund has related to the lack of representation of NGOs and vulnerable groups on the Country Coordinating Mechanisms (CCM) - through which local stakeholders make grant proposals and receive financial support - and the CCM's effectiveness, transparency and independence from governments.
But the Global Fund has also been recognised as more than a funding mechanism. "The Fund is rewriting the rules on delivering assistance. It tries to marry the best of all other instruments - an emergency spirit, recipient-owned programmes, and participatory processes", while addressing the problems that have emerged, noted Mabel van Oranje of the Open Society Institute.
The local ownership of programmes helps counter what has been described as "donor-driven agendas". "Take PEPFAR for example," said van Oranje in a presentation at the conference reviewing new funding mechanisms. "It earmarks a specific proportion of spending for abstinence-only programmes.
"At issue is not only the effectiveness of the 'A' of 'Abstinence' versus the 'B' of 'Being faithful' or the 'C' of using 'Condoms', it is also about whether in-country experts should design programmes shaped by realities on the ground: in Africa many new infections occur in monogamous married women - they are already 'being faithful' and 'abstinence' is just not an option."
But the Global Fund is at a critical juncture, needing at least US $1.4 billion in 2004 and $3.4 billion in 2005, according to a report by the International Council of AIDS Service Organisations (ICASO). Only $800 million has been so far pledged towards next year's requirement.
Among the demands of chanting activists at the conference has been to "fund the Fund". They have pointed to Bush's allocation of $200 million to the Geneva-based organisation for 2005, the $85 million Germany has promised, and the zero pledge from Japan, as evidence of the failure of key, wealthy countries to commit to what remains a unique grant-making agency.
"Donor governments need to view the Global Fund in the same way that they view their other national priorities, like contributions to international peacekeeping, or investments in domestic school systems. The Global Fund must be based on a truly joint and long-term global commitment to financing the war on AIDS, TB and malaria," ICASO urged in its report.
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Prostitutes protest AIDS-drug test, tenofovir for preventing HIV infection: Bay Area company hit with charges of exploitation
San Francisco Chronicle
July 14, 2004
By Sabin Russell
Bangkok - On the podium in the Grand Ballroom at the 15th International AIDS Conference, Johns Hopkins University infectious-disease researcher Dr. Joel Gallant suddenly found himself surrounded Tuesday by angry, chanting Cambodian prostitutes.
Gallant was presiding over a seminar on antiviral drugs, and the protesters were demanding a halt to a planned trial designed to determine whether a proven AIDS drug might have a second use -- blocking infection with HIV as effectively as a vaccine.
About 30 protesters, who took over the stage for 15 minutes, held signs declaring the maker of the drug, Gilead Sciences of Foster City, "uses sex workers for free."
For Gilead, a little-known company, the disruption was another sign that it had hit the big time in the politically charged world of AIDS medicine, an inevitable outcome of its enormous success in bringing to market one of the safest and most effective antiviral drugs for patients with HIV.
"The fact that part of our pharmaceutical company makes a living in HIV - - that alone draws attention. As these things go, you can't win," said Norbert Bishofberger, Gilead's executive vice president for research and development.
The protesters, led by ACT UP Paris, were demanding that Gilead, sponsor of the disrupted seminar, provide lifetime health care for any participant in the study who became HIV-positive -- a price they felt the company should pay for allegedly endangering the lives of the young women who enrolled in the experiment.
Dr. James Rooney, the company's vice president for clinical affairs, said the study, which will involve the use of a placebo, was designed to comply with strict ethical guidelines. A community advisory board, he noted, calls the experiment "the hope of women.''
At a conference that is virtually guaranteed to be short on major scientific breakthroughs, Gilead's drug tenofovir, or Viread, is grabbing the spotlight. In the two years since it came on the market, it has reshaped the prescribing patterns of AIDS doctors -- and has added a new wrinkle in the debate over bringing low-cost drugs to the developing world.
"For us, tenofovir is an incredibly important drug,'' said Rachel Cohen of the French medical organization Doctors Without Borders. Because of its safety and relatively low cost, it is a prime candidate to serve as a second line of defense for patients in poor countries who fail to respond to less expensive "first line" therapies.
Although Gilead has offered to sell tenofovir for its stated cost of 80 cents a pill to 68 poor countries, Cohen said the price is not nearly low enough to ease the problem of treating millions of AIDS patients. Doctors Without Borders would like to see prices closer to 30 cents a day.
Cohen expressed skepticism that Gilead could make good on its offer. He noted that the company hasn't obtained government approval to market the drug in many of the poorest countries. "If it is not registered, then the offer of 80 cents is a virtual one,'' she said.
It was an entirely different issue, however, that brought out the protesters from ACT UP. Scientists have been eager to test tenofovir as a potential chemical shield against HIV after studies showed it worked 100 percent of the time on monkeys. Those tests used an intravenous form of the drug, however, and protected the animals against the simian immunodeficieny virus, a cousin of the AIDS virus that can kill macaques.
According to Rooney, 900 HIV-negative "beer girls," who work the bars in Phnom Penh, are being recruited for a study in which some will be given tenofovir and others, a placebo. After a year, the women will be tested to see whether there are fewer HIV cases among those who got the drug.
The study is in fact being conducted not by Gilead but by researchers at UCSF, funded by the federal Centers for Disease Control and Prevention. The CDC is sponsoring similar tests in Atlanta, and the Bill and Melinda Gates Foundation is underwriting pre-exposure prophylaxis trials in Africa. Gilead's role is to provide the drugs for free.
All the women will be counseled to use condoms and will be supplied with them following rules used in vaccine trials.
But in the view of Tuesday's vocal critics, the study offers only cursory safer sex counseling. Protesters called the test unethical and demanded that it be halted. The Cambodian prostitutes contend that the study won't work unless some of them become infected, leaving them pawns in a corporate drug development scheme. "Gilead Prefers Us HIV +" read one sex worker's placard.
The bottom line for protesters, however, was a bid to require Gilead to provide health care to any study participants who become ill.
Although Gilead itself is a relatively young company and new to the world of angry AIDS protests, it has a powerful board of directors familiar with corporate power and controversy. Among its members: former Secretary of State George Shultz, former Intel chairman Gordon Moore and Stanford Nobel laureate Dr. Paul Berg. And chairing Gilead's board, from 1997 until 2001, was none other than current secretary of defense, Donald Rumsfeld.
Tenofovir, a variant of AIDS drugs that block a key enzyme in HIV called reverse transcriptase, was acquired by Gilead from a Czech chemist, Antonin Holy, and cobbled into a once-a-day pill approved for marketing by the Food and Drug Administration in October 2001 -- an event vastly overshadowed by the terrorist attacks only weeks before.
Just before the opening of this year's AIDS conference, the Journal of the American Medical Association published results of a three-year study comparing tenofovir to stavudine, or D4T, one of the most widely prescribed AIDS drugs. The study was led by Johns Hopkins' Gallant and showed that the Gilead drug was just as effective as D4T but caused only a fraction of the side effects, such as the disfiguring shifting of fat from the face and limbs to the belly.
Doctors have already been aware of the relative safety of tenofovir, and it has quietly become the most widely prescribed AIDS drug in the United States, according to NDC, a market tracking firm. Gilead's sales of Viread during the first quarter ended in March were $193 million.
Viread is not Gilead's only AIDS drug. A companion medication called emtricitabine, or Emtriva, also has been approved for marketing, and Gilead is in exploratory talks with Bristol-Myers Squibb to develop a single pill that would combine three AIDS drugs into a single, once-a-day pill.
That could once again alter the dynamics of drug sales to the developing world, as it would offer a more expensive, but arguably safer, "fixed dose combination" pill than that being made for Third World patients for as low as 40 cents a day.
Such a pill, from a politically well-connected company such as Gilead, might also find favor with the President's Emergency Program for AIDS Relief, the Bush administration's $15 billion overseas AIDS initiative, which has not, to date, accepted any generic medicines.
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